Rebecca TernesDeputy Commissioner

North Dakota Insurance Department

Supreme Court Ruling

Employer Health Insurance Requirements

Health Insurance Exchange

Essential Health Benefits

What’s Next for Healthcare Reform?

5-4 split vote Congress can tax people with enough income

that choose to go without health insurance. The Federal government does not have the

power to force people to buy insurance but it does have the power to impose a tax on those without health insurance.

The mandate was important to avoid adverse selection.

States cannot lose federal funding for Medicaid programs if they do not expand.

Half of businesses with 3-9 workers provide health insurance

73% of businesses with 10-24 workers provide health insurance

98% of businesses with 200+ workers provide health insurance

About 1 in 4 business owners are uninsured in U.S. which makes them individual buyers

Source: Kaiser Family Foundation Policy Insights, September 28, 2012

More than 200 employees—must auto enroll employees (opt-out)

More than 50 employees—must provide essential coverage or pay penalties

50 or fewer employees—exempt

Counting employees will be different

Pay for employeeinsurance Good will Competitive benefit

structure Incentivizing better

health of employees and reducing costs

Tax credits for employers with up to 25 employees

Pay the penalties Save money One less business

decision, less hassle keeping everyone happy

Allow employees to buy in or out of Exchange

Individual and small-business (SHOP) Exchange must exist (can be combined)

Exchange in every state by Jan. 1, 2014 (operational by October 1, 2013)◦State-based Exchange◦Partnership◦Federally-facilitated Exchange

Outside market remains intact—grandfathered and nongrandfathered

Facilitate comparisons and purchases Administer subsidies Provide standard comparative info Rate plans on cost and quality Certify individual mandate exemptions Coordinate with Medicaid and CHIP Establish Navigators program Be operational by October 1, 2013 and

fully functioning by January 1, 2014

Traditional employer model◦ Employer enrolls and makes choice of plan(s) for

employees

or

Employee choice◦ Employer chooses benefit level (metals)◦ Employee picks which insurer and which plan

within metal category◦ Defined Contribution only

Applied for and received $1 million Exchange Planning Grant

Completed study in December 2011 Bill in 2011 regular session to plan for

implementation Bill in 2011 special session for state-based

Exchange—failed 64-30 Leaves us with a Federally Facilitated

Exchange for now Final decision date is November 16, 2012

Will have to be included in nongrandfathered plans ◦Individual and small group markets◦In and outside of the Exchange, Medicaid

benchmark and benchmark-equivalent and basic health programs

Items and services in 10 categories:◦ Ambulatory patient services◦ Emergency services◦ Hospitalization◦ Maternity and newborn care◦ Mental health, substance abuse disorder services◦ Prescription drugs◦ Rehabilitative and habilitative services and devices◦ Laboratory services◦ Preventive, wellness, chronic disease management◦ Pediatric services, including dental and vision

March 31, 2012: determine potential plans from four options:◦Largest plan by enrollment in any of the

three largest small group insurance products in the state

◦Any of the largest three state employee health benefit plans by enrollment

◦Any of the largest three national FEHBP plans by enrollment

◦Largest insured commercial non-Medicaid HMO

September 30, 2012: recommend to the Secretary of HHS the state’s benchmark plan

Secretary will determine if the plan:◦ Meets 10 category requirements◦ Reflects typical employer plan◦ Accounts for diverse needs◦ Ensures there are no incentives to discriminate◦ Ensures compliance with Mental Health Parity Act◦ Provides states a role in defining EHB◦ Balances comprehensiveness and affordability

Should a state not choose a benchmark plan, the default plan would be the small group plan with the largest enrollment

Approved plan will be the benchmark for 2014 and 2015. HHS intends to review and update EHB for 2016 and beyond.

EHB is thought of as a floor—insurers may add to the benefits and price accordingly, but they cannot take benefits away

Basic plan vs. rich plan◦Pricing increases◦Premium value◦Insurer competition◦Network adequacy

Choosing a richer plan◦Likely to cause insurers to request

premium rate increases◦Affordability◦Specific coverage may cause a plan to be

more or less expensive (e.g., fertility benefits vs. laboratory services)

◦May force employers and individuals to purchase insurance they do not want or need

Choosing a basic plan◦Possible market disruption—ND plans are

traditionally fairly rich◦Small employers may terminate previous,

richer plans for cheaper basic plans◦Allows insurers to design unique plans to

compete◦More variation for employers and

individuals shopping in or out of the Exchange

Analysis Legislative hearings Commissioner sent in a benchmark

submission on September 28 ND recommendation was the Sanford

Health Plan plus the CHIP pediatric dental and vision benefits

HHS Secretary will now publish choices, take comment and make final decision.

Date???

Lots of work for insurers to get ready for 2014 Complex decisions for employers, employees

and individual health insurance consumers Training for agents and agencies Insurance Department to work with the

Exchange NDDHS Medicaid to work with the Exchange Continued implementation of market reforms Election Results? Congressional action?

1-800-247-0560insurance@nd.govwww.nd.gov/ndins