2015 Will Arkansas be operating as a State
Partnership Marketplace or will Arkansas become a State-Based Marketplace?
Implications for the Small Group Market and Small Employer Health Options Program (SHOP): Employer or employee choice model Active purchaser or market based
Key Aspects for Employers
New definition of Small Group moves to 100 employees in 2016 Rating rules apply to 50-100 groups Essential Health Benefits (EHB) package applies to 50-100 groups New way rates are built for 50-100 groups
HHS has reserved the right to define “Essential Health Benefits” Package for 2016 May result in a standardized EHB in all 50 States
State waiver for private option ends in 2016
Known Changes to the Market beyond 2015
New Rating Methodology for 50-100 in 2016
Gender rating removed Industry rating removed Common geographic rating established by regulators Tobacco load nationally 50% (Arkansas 20%) Health status and pre-existing conditions no longer considered Age rating reduced from 6:1 ratio oldest to youngest to 3:1
Essential Health Benefits
Prescription drugs
Rehabilitative and “habilitative” services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including dental and vision care
Non-grandfathered small group health plans – offered on or off the SHOP, must provide these government-mandated essential health benefits
Essential health benefits include services in the following 10 categories:
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substanceuse disorder services, including behavioral health treatment
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Premium Rate Calculation
Unique rate calculation for every member Member-level, rather than employee-level, census
required to comply Every member on an employee contract has a
unique rate
Rates developed for up to 3 minor children 4th minor child (and any additional) is free Children age 21+ must be rated as adults
2017 Marketplace
Marketplace can allow large groups (100+) to purchase through online marketplaces similar to SHOP for small employer groups. Implications
Essential Health Benefits Package
Employee Choice Model
Employer Open Enrollment Period
“Large Group” Purchasing on Marketplace
Self-Funding
Grandfathering
Defined contribution through private exchanges
Employer Strategies to Stay “Outside Marketplace”
Employee/Incentives to drive engagement (Wellness and Health Management Incentives/Programs)
Medical Home Models
Health Improvement Tools
Employer Strategies to Control Costs
Management of “pre-crisis” chronic conditions – new models of Case Management
Focused Provider Panels Home Monitoring, Electronic Health Reference-based pricing Onsite health care New payment mechanism
Employer Strategies to Stay “Off Exchange” and Control Costs