Health Insurance and You!

With funding from the Robert Wood Johnson Foundation, the Georgetown Health Policy Institute recently published options for states and Exchanges to consider in improving healthcare quality for their residents. These options are not required by the ACA and are intended for states with the resources to further quality improvement goals. In this article, we address some of the strategies proposed in the Georgetown findings that have promise.

Highly Specific Quality Ratings. Although the ACA requires Exchanges to provide quality ratings for plans offered, Exchanges can set higher standards than ACA requirements. The Georgetown article proposes that Exchanges can provide quality metrics based on specific health care services. For example, a user can assess which plans perform better for managing diabetes vs. high blood pressure.

We support a robust quality ratings system for state Exchanges. NCQA HEDIS and CAHPS scores, as well as other performance measures, help inform consumers and can only be positive for quality improvement efforts. Getinsured.com is the first private health insurance Exchange in the nation to integrate NCQA ratings into its plans.

Aligning Reimbursement and Quality Improvement Strategies. The authors propose that such aligning could be done for both public and private health plans. The intention is to have a “critical mass” of health plans notifying provider networks about quality improvement issues. We support this option as long as the alignment between reimbursement and quality improvement strategies are clear, reasonable and not too burdensome on health care providers.

Piggybacking on Federal Efforts. The federal government has various quality improvement strategies to complement state efforts. HHS is providing Exchange Establishment Grants that states can seek to limit the cost of their quality improvement plans. There are also national quality improvement programs for states to look to such as the National Quality Strategy and Medicare Advantage quality ratings.

Performance Based Contracting. The authors propose that the quality standards bar to sell plans on the Exchange be higher than those required under the ACA. This would make the Exchange selective contractors rather than market organizers, an area of contention in some states and for good reason. However, creating additional quality criteria for QHP certification may strengthen the partnership between the Exchange and plan carriers, creating more bargaining power in pushing quality improvement standards on health care providers.

Quality improvement is a goal that most if not all health reform stakeholders can sign onto. For this reason, it is a good idea for state Exchanges to set the groundwork for incenting quality improvement early, so that future efforts can build on it. The above strategies encourage such groundwork, and states should gauge community support for each in preparing their Exchanges for 2014.

State-based health insurance exchanges – online marketplaces for health insurance coverage – are a key piece of the 2010 health reform law. Recently, the National Governors Association (NGA) released an issue brief summarizing the goals that states might pursue when it comes to health insurance exchanges and children, and how states could try to maximize kids’ access not only to insurance coverage, but to other programs administered by the state. NGA cites the importance of market and policy decisions, such as regulating the plans that are available, the ways in which they share risk, and the role of brokers; as well as operational decisions, such as enrollment processes and the mechanics of the online exchange.

According to the NGA, goals for children’s coverage include “promoting continuity of coverage, creating a one-stop portal for public programs, maintaining benefit packages and cost-sharing requirements, and emphasizing outreach activities.” Shifting eligibility rules and other changes resulting from health reform will lead to many changes in children’s health insurance in the next few years, and the authors of the issue brief emphasize the importance of maintaining kids’ coverage throughout this transition.

Continuity of coverage becomes important near the edges of eligibility rules – for example, when a family’s income is on the threshold of being eligible for Medicaid, and the child may go back and forth between Medicaid coverage and coverage through the exchange. NGA suggests that states encourage health insurers and plans to participate in both types of programs, so that children can keep similar coverage through changes in family income.

Using a health insurance exchange as a one-stop portal for public programs would, once fully implemented, simplify paperwork for both states and their residents. For example, if two unrelated social services programs have similar eligibility requirements, a person would have to apply only once, and information could be stored in the system for future use. The challenge in meeting this goal is putting that system into place; states run numerous programs, and creating an integrated portal would take a lot of work up front.

Maintaining benefit packages and cost-sharing requirements is important for children and families who currently or may in the future rely on specific benefits from these programs. According to the NGA, children who transition between Medicaid and exchange-based insurance would, ideally, maintain not only their coverage, but also the details of that coverage. If the benefits and cost-sharing rules change from plan to plan, enrollees would experience more confusion, administration would be more complicated, and unexpected medical expenses would be more common.

Lastly, NGA emphasizes the importance of outreach and marketing, in order to get consumers aware of the options that are available and enrolled in the plans that best suit them. NGA suggests that states, familiar with outreach for Medicaid and other existing public programs, apply the same strategies when reaching out to people who would use an exchange. Brokers, who also have an incentive for enrolling more customers, should be involved as well.

Readers, how open are you to buying insurance for your child through an exchange? Are there other issues that states should have on their radar as they continue to design their exchanges?

Online health insurance exchanges are new, uncharted territory for many groups. Several of our recent tweets and blog entries have considered the challenges that states and the federal government are facing in deciding how to organize and run these new programs, but what about the technology companies that will actually be building them?

According to an article by Alina Selyukh of Reuters, the tech world is excited about this new opportunity. Companies like Hewlett Packard, Deloitte, Dell, and Oracle are vying for contracts to create the exchanges, which could be worth $5-100 million per state. States that want their own exchanges have less than a year and a half to present their plans to the federal government, and so for tech companies wanting to get involved, the time is now.

As the new, state-based exchanges take shape, what many people forget is that health insurance exchanges already exist. We’re one example. Ms. Selyukh writes, “An average exchange would allow people or small businesses to shop around for an insurance plan similar to how one would shop for insurance on online broker sites such as eHealthInsurance.com or GetInsured.com.”

For those who may be new to our blog and our site, Getinsured.com is a commercial health insurance exchange that has operated since 2005 and services over one million customers per year. We focus on the individual market, helping people electronically shop, compare and enroll in over 6,000 health insurance plans from 49 of the nation’s leading carriers. With so many choices, our talented brokers work with customers to find the best, most affordable plan that fits their health insurance needs.

But it doesn’t stop there. Getinsured.com also specializes in customizing exchange solutions to meet the diverse needs of state governments. Our exchange software and support services are comprehensive and available both independently and as an integrated whole, allowing our government customers to create a flexible plan with the features they want.

A couple of weeks ago, we blogged about two schools of thought on the role of health insurance exchanges, online health insurance marketplaces that will be created by each state as part of health reform. By combining individuals and small businesses into a larger group, exchanges will reduce customers’ collective risk, increasing their purchasing power and access to an affordable plan.

The White House’s original description of how exchanges would look left plenty of room for creativity on the part of states, provided they were ready by 2014. Since then, states have formed committees to explore options and begun establishing and planning their systems – some with the help of federal funds.

Yesterday, the Department of Health and Human Services (HHS) proposed new guidance on exchanges. The agency is accepting public comment on these ideas for the next 75 days. According to an article by Robert Pear of the New York Times, the new rules include:

• An “operational assessment” of each state’s exchange in January 2013, one year before they must be ready. For any state that is not able to (or unwilling to) operate its exchange, the federal government may take over its operation. In an article for Reuters, Alina Selyukh and Anna Yukhananov explain that the deadline offers some flexibility on timing for states that want to participate but are not fully ready by 2014.
• Subsidies to help customers afford insurance coverage through the exchange. People with incomes up to four times the poverty level will be eligible for assistance, on a sliding scale.
• Requirement that each state’s exchange certifies “qualified health plans,” includes standardized information comparing the costs and benefits of each plan, and rates plans based on the quality and price of the care they cover.

Every health plan must also offer a set of essential health benefits. What counts as “essential” is not yet determined, but HHS expects to have an answer later this year.

According to an article by Anna Wilde Matthews of the Wall Street Journal, these rules still leave states with lots of decisions. These include:

• How insurers can market their plans within the state
• What kind of networks of health providers plans must include
• How small-business versions of the exchanges will work and how much choice employees will have
• Whether to partner with the federal government to set up the exchange

As exchanges and other aspects of health reform are implemented in the next few years, HHS plans to issue more guidance in the next few years to help them take shape.

Exchange administrators face unique challenges when it comes to implementing federal health care reform in a manner suitable for our rural citizens. In this article, we look at some of these issues, which may be present in certain urban settings as well.

Access to Doctors and Hospitals

Although rural citizens represent 20 percent of the country’s population, only 10 percent of U.S. doctors service rural areas—with 1/3 as many specialists as in urban areas. Since there are far fewer specialists, many rural citizens are forced to travel long distances to get the care that they need. Ideally, Exchange administrators should be able to rate the strength of an insurance plan’s provider network according to specific county before offering it on the Exchange. States that lack such abilities may wish to consider being more plan-inclusive in their overall certification process.

Access to the Internet

Seventy-five percent of rural citizens have access to broadband Internet—compared with 93 percent of urban citizens. In other words, 1 in 4 rural citizens may not have online access to Exchanges. Some states like Alabama have installed enrollment kiosks at community health centers and public health departments—we think this approach is promising. But the traditional bedrock of rural support has been the independent health insurance agent. We believe that the training of traditional agents and navigators to support the Exchange is critical to efficiency in reaching rural communities.

Eligibility Determination and Continuity of Providers

A greater proportion of our rural citizens have seasonal jobs in occupations such as agriculture, where their incomes vary widely over the year. In turn, such varying incomes pose challenges for eligibility determination and continuity of coverage.

• Income verification—It is critical to have guidelines on how often income verification needs to occur in an Exchange, and what events if any would trigger eligibility redetermination.

• Provider continuity—Some in government and public policy have discussed the importance of having health insurance plans with common provider networks in both the Medicaid and health insurance markets. This is clearly important, but requires full insurance carrier buy-in. A second approach to provider continuity is to offer citizens sophisticated provider selection and analysis tools when selecting their health insurance plan.

• Lack of payment instruments—A small but significant percentage of rural citizens lack access to checking accounts, credit cards or debit cards. Thus, it is important that Exchanges develop mechanisms for accommodating such citizens.

• Lack of income tax filing—About 10 percent of the nation does not file taxes, and this proportion is even higher for rural citizens. The MAGI-based eligibility determination schemes in the ACA for Medicaid will need to address the issue of how the Exchange will conduct eligibility determination for such citizens.

In related news, the HHS’ National Advisory Committee on Rural Health and Human Services will hold its second meeting of the year from June 15-17, 2011. By design, the meeting will be held on-site in Traverse City, Michigan. The Committee, chaired by former Mississippi governor Ronnie Musgrove, addressed some rural implications for health Exchanges back in February, but plans to thoroughly focus on them in the coming year.

On May 24, Getinsured was in Sacramento, CA to participate in the California Health Benefit Exchange’s third board of directors meeting. The meeting covered various topics, but most of the discussion was about integrating the state’s eligibility determination processes for its public assistance programs. While far from perfect, the current infrastructure appears to provide a good web and data-sharing framework for California’s Exchange to build on in implementing ACA requirements.

At the meeting, the County Welfare Directors Association (CWDA) and the Managed Risk Medical Insurance Board (MRMIB) presented the two main eligibility and enrollment systems for California’s public health programs. The CWDA provided information about the state’s county-based eligibility determination process, whereas the MRMIB provided information about California’s statewide eligibility determination process. While there is some overlap between the two processes, there also appear to be substantial gaps.

The county-based eligibility method assists Californians in determining their eligibility and enrolling in Medi-Cal (the state’s Medicaid Program), County Medical Services Programs, and other non-healthcare based programs. To enroll, individuals apply according to their county of residence. There are 58 county social service departments in California that are supported by 3 different automated eligibility systems, but all applicants can start the process from a single web portal (www.benefitscal.org). Alternatively, MRMIB discussed a statewide eligibility and enrollment process called the Health E-App (www.healtheapp.net), which has a “Single Point of Entry” process for Medi-Cal, Healthy Families (California’s CHIP initiative) and other public health programs not currently available in the county-based model.

Both eligibility determination processes cannot co-exist under the ACA because they screen for different public programs from different portals. A logical next step is to seamlessly integrate the county-based portal and the Health E-App portal. The ACA requires a one-stop shop for health insurance and individuals should not have to enter their eligibility information twice. Over the next 6 months, such critical decisions are ahead for the California Health Benefit Exchange Board, which also released the following eligibility and enrollment timeline for implementation.

Terri Shaw, project director for Enrollment UX 2014, also briefed the board about their national initiative to help states implement optimal user experience on their Exchanges. She discussed the potential need for Exchanges to accommodate the growing number of tablet users, which are estimated to almost triple in number by 2014 to 71 million users.

The board is still awaiting its 5th member, who will be appointed by the California senate, but their next meeting is scheduled for June 15, 2011. CMS Director Cindy Mann and HHS Director Joel Ario are scheduled to attend, which will provide a unique federal perspective to the Exchange implementation discussions of the state.

Prior to September 23, 2010, insurance companies could lawfully deny coverage to seriously sick children. Pre-existing conditions such as diabetes or asthma were enough to disqualify a child from coverage. However, following the passing of the Patient Protection and Affordable Care Act, insurers can no longer deny coverage for children, including those with pre-existing conditions. California state legislators acknowledge that this law of expanded coverage is ineffective without additional measures to prevent parents from being charged more than double the rates for healthy children, in California. It should be noted that these lowered rates are only available during specific “open enrollment periods.” Aside from these periods of lowered rates, the cost of insurance can be as much as 20% higher, according to California State Insurance Commissioner Dave Jones.

That said, the open enrollment period deadline is today, March 1st 2010. If you haven’t applied for your child’s coverage by today, you still have a chance to take advantage of these lowered rates during upcoming open enrollment periods. Following today’s deadline, the next open enrollment period is defined as the month of your child’s birthday. For example, if your child was born in May, then May is considered an open enrollment period for your child.

Please take the time to spread this news by sharing this information with friends, family, and members of your community so that those in need can take advantage of this great window of opportunity.

To find out more, visit your state’s department of insurance website.

Last Wednesday, the U.S. Department of Health and Human Services (HHS) awarded seven states a total of $241 million in grants to develop online health insurance shopping systems, according to a recent article by Noam Levey of the Los Angeles Times. The seven grants, part of HHS’ Early Innovator program, were awarded to state health and insurance departments and one medical school, their values ranging from about $6 to $54 million each. The states that received grants include Kansas, Maryland, Massachusetts, New York, Oklahoma, Oregon and Wisconsin.

Because states understand their own health insurance markets and needs so well, HHS hopes that piloting different approaches in multiple states will result in a comprehensive data set of what will and will not work. To make sure the results are applicable to the country as a whole, the states that received grants were of varying sizes and populations, in different regions.

Through these online health insurance shopping systems, HHS will implement the health insurance exchanges that were passed as part of the health care law in March 2010. By 2014, the exchanges will be up and running, and Americans will be able to use them to shop for health insurance in a direct and easy way. According to the Congressional Budget Office, the agency that reviews Congress’ budget and its implications, about 24 million Americans without employer-sponsored health insurance will be insured through the exchanges by 2019.

In these exchanges, health insurance companies would compete for customers more simply and transparently, the way providers of other services compete. According to a press release from HHS, the systems will allow “individuals and small business owners to pool their purchasing power to negotiate lower rates.”

Sound familiar? It’s because we at GetInsured.com have a similar goal: to provide you, our customers, with an affordable health solution. For the past few years, we have successfully done what these seven new systems will try to do on a state-by-state basis. Now that the government is getting on board, it looks like easy, cost-conscious health insurance options are the way of the future. And that is a great thing.

In a recent Washington Post article, journalist Ezra Klein examines the importance of the individual mandate to health care reform, using as a model the mandate established in Massachusetts in 2006. According to Klein, the individual mandate makes all the difference in making health insurance premiums affordable.

“There are a couple of reasons for Massachusetts’ success. One is that the market is more transparent, and so insurers are competing more aggressively against one another…The bigger reason is that the individual mandate – plus the combining of individual and small firms in the same insurance market – brought healthier, younger people into the mix, which brought average premiums down for everybody,” he writes.

Since the change was enacted, average premiums in Massachusetts have dropped by 40%, compared to a 14% increase nationwide during that same period. The percentage of Massachusetts adults who are uninsured has also dropped dramatically, from 3.0% in 2008 to 2.4% in 2010, while the national percentage has increased from 14.8% to 16.3% during those years. The decrease in Massachusetts is all the more remarkable in light of the current economy; during a recession, uninsured rates usually go up because fewer people are employed and able to receive employer-sponsored health benefits.

If the individual mandate – currently being debated by the U.S. Supreme Court – is implemented nationally and aided by mechanisms like health insurance exchanges, Klein argues that we can expect similar results on a nationwide scale. As CEO and Founder of GetInsured.com, I imagine that services like ours will become increasingly important as a new set of consumers are brought to the health insurance market, many for the first time.

Our work would benefit consumers more familiar with the market as well, since a health insurance exchange would usher in a number of new plan options, rules and regulations, and processes to match consumers with insurance plans and administer those plans. In addition, as the market becomes more transparent, our experts will be on hand to help consumers sort through all the newly available information and use that information to find the best plan for them.

As reported recently in the media, the federal government has announced plans to decrease premiums for high-risk pools established under the Patient Protection and Affordable Care Act. Premiums are expected to decrease by about 20% in the 23 states (and District of Columbia) in which the government manages the pools. If you are part of a high-risk pool in one of these states, expect to see a decrease in your premium effective January, according to Karen Pollitz, head of the Health and Human Services Office of Consumer Support.

Additionally, those enrolled in these states’ high-risk pools will have the opportunity to choose among the following types of plans:

1) A plan with a $1,000 deductible for medical expenses and a $250 prescription drug deductible, or

2) a plan with a $2,000 medical expense deductible and a $500 prescription drug deductible.

These improvements to current federally run high-risk pools should alleviate some of the burden off of consumers–which has been the original intention behind high-risk pools since their inception. These pools are meant to bridge the coverage gap for those with preexisting conditions, until 2014, when low income Americans will be able to take advantage of subsidies towards traditional health insurance plans. Granted, enrollment in these high-risk pools has gotten off to a sluggish start, “we expect we’re going to see enrollment really grow” said a confident Pollitz, at the Health Affairs media breakfast.