I N S U RA N C E P O O L S BY S TAT E

HEALTH INSURANCE EXCHANGES (HIX)

HEALTH INSURANCE EXCHANGES

• Required for 2014 in every state and U.S. territory• Affordable Care Act 2010 • Administered by• State Alone• Federal Alone• Combination of State and Federal

• To Date• 18 states and District of Colombia are electing to do it

alone• 26 states are choosing the Federal Exchange• 7 states are choosing a combination

EXCHANGES & POLICIES

• Government Regulated• Standardized health care plans• Must provide basic coverage

• Eligible for Government Subsidies• Low income individuals can select plan and part of cost paid by

Federal Government

• Guaranteed Issue• Must be available to all and cannot exclude based on pre-

existing condition

• Exchange must be Government Certified• Exchanges do not offer policies themselves but

regulate which companies can offer policies through the Exchange

EXCHANGES & POLICIES

• What Exactly Does an Exchange Do?• Allows individuals and small businesses to shop and

compare different private health care offerings• Provide information on the various plans and their

coverage options, subsidies available• Market place for private insurance companies to list their

insurance coverage and prices• Intent is to provide lower cost for individuals and small

business by providing a competitive market place

• What do you do?• If you need insurance or are a small business providing

insurance, compare and sign-up for policies

EXCHANGES & POLICIES

• Key Features of the Law (Exchanges)• Plans must supply Summary of Benefits and Costs (SBC)• Glossary of terms standardized• Examples of how coverage works for Type 2 Diabetes or

delivery of a baby

• Federal Support of Consumer Assistance Programs• Rules for appeal of a claim denial and requirements of

the policy issuer• Free access to preventive care (detailed on next slide)• Patients Bill of Rights• From right to choose doctor to eliminating exclusion for pre-

existing conditions to review of premium increases

EXCHANGES & POLICIES

• Preventive Care Free Access for• Blood pressure, diabetes and cholesterol tests• Cancer screenings for mammograms and colonoscopies• Programs for quitting smoking, weight loss, healthy

eating, alcohol dependency, and treating depression• Well baby and Well child visits• Routine vaccinations• Measles• Polio• Meningitis• Flu

• Healthy pregnancies (counseling, screenings, vaccinations)

EXCHANGES & POLICIES

• About the Plans• Four levels (Bronze, Silver, Gold, Platinum)• Bronze – cheapest and most basic coverage• Platinum – Highest cost with greatest coverage

• 80/20 Rule• Only 20% of your premium can be for administrative costs• 80% must be spent on actual coverage of patients (in pool)

• Pricing Variations• Smokers can be charged 1.5 times higher• Age differences up to 3.0 times higher• Premium plans cannot exceed 4.5 times the lowest cost plan• Some variations within state regions and family composition

EXCHANGES & POLICIES

• What is coming in 2014?• Fully operational exchanges in all fifty states, District of

Columbia and U.S. territories• Tax credits for families making between 100% and 400%

of the federal poverty level for policy purchases with about 9 out of 10 policy holders in exchanges receiving some type of subsidy

• Tax penalties for not getting insurance coverage• 12 million Americans purchasing insurance through the

health insurance exchanges growing to 29 million by 2021

• QUESTIONS?