Setting the record straight on health law’s delayed small business features

The Department of Health and Human Services’ proposal to delay critical requirements for small business health insurance exchanges in some states is a disappointment to Small Business Majority and millions of small businesses. It’s a letdown to small business owners and their employees looking forward to robust, competitive exchanges in 2014. We hope this proposal is recognized as counterproductive and is abandoned. 

That said, there’s a tremendous amount of misinformation circulating about what the rule would actually mean. We want to set the record straight.

What the Rule Would Do
The proposed rule would delay two features of small business exchanges in some states until 2015. It would not delay opening of the exchanges themselves. Exchanges will still open Jan. 1, 2014.

The rule would mean that in some states, two features of the exchange won’t be implemented: 1) employee choice and 2) premium aggregation. These are wonky healthcare terms, but the impact their delay would have is fairly straightforward. Stalling employee choice means small employers will have to wait until 2015 to be able to offer workers an array of health plans to choose from. Delaying premium aggregation means an administrative function that would simplify the payment process for employers also won’t be available for a year. The two features are linked—premium aggregation is not needed without employee choice.

The Facts
Exchanges still open; small businesses still have more than one plan option
What the rule would not do—despite a multitude of reports saying otherwise—is strip small businesses of any coverage choice whatsoever, essentially forcing all small business employers and their workers into one health plan.

Indeed, word on the street is that all small businesses that enroll in exchanges will have access to only one plan. Some reports have even gone as far as saying this plan will be government-run. Neither one of these is true.

Multiple private plans still available
Whether the rule is finalized or not, come 2014, two things will be true: there will be a full array of private health plans offered through the small business exchanges, and employers will be able to choose a plan from them. Their employees can then decide whether to enroll in it. This is essentially how the small group market works right now. What the rule means is that employees themselves will not have a menu of plans to choose from until 2015—which is a new benefit the law provides for small businesses.

Only applies to certain states
It’s also important to note the rule requires only states that have federally facilitated exchanges to delay these features a year. Federally facilitated exchanges are those created by the federal government in states that haven’t chosen to create them on their own. The 17 states implementing their own exchanges can still extend employee choice and premium aggregation to their customers starting in 2014. Nearly 40% of small businesses in this country do business in the 17 states implementing their own exchanges. That means there will be employee choice among health plans for those businesses next year—if their states choose to give it to them.

No impact on self-employed
What’s more, delaying this rule does not impact America’s 22 million self-employed individuals, nearly 30% of whom are uninsured. As planned, these entrepreneurs will still be able to purchase insurance through the individual exchanges in 2014—a huge boon to owners who have struggled to purchase affordable insurance for decades.

The Bottom Line
While certainly disappointing, delaying employee choice and premium aggregation is not the end of the world. Starting next year, small employers will still be able to pool their buying power in the exchanges, giving them the kind of clout large businesses currently enjoy. They’ll still get administrative help and, in many places, will have more choices of plans than they currently do. All the original features of exchanges will go into effect in 2015.

Small Business Majority has been talking to real small businesses across the country since the law was passed three years ago. We know they like the features of the exchange that could be delayed, along with other key provisions including: 1) being able to pool their buying power; 2) the Medical Loss Ratio provision requiring insurers to spend 80% of premium dollars on care; and 3) the preexisting condition ban. Our national opinion polling further underscores this.

We hope the proposed rule isn’t finalized, because small businesses nationwide are looking forward to employee choice and premium aggregation. Nevertheless, these features will still be in the exchanges in 2015—albeit a year late.

John Arensmeyer 
Founder & CEO, Small Business Majority



(This post was originally posted here on the Small Business Majority blog)

One Step Closer to Knowing - DOI Issues QHP Guidance

Under the Affordable Care Act, one of the new options for individuals and small businesses to buy health insurance for themselves and their employees in 2014 will be the Illinois health insurance exchange or "marketplace."  On March 29, 2013, the Illinois Department of Insurance (DOI) issued guidance to Illinois insurers about the requirements for a plan to be certified as a Qualified Health Plan (QHP), which means that they meet all of the coverage and cost-sharing requirements of the Affordable Care Act and can be sold in the Illinois Marketplace. This brings us one step closer to knowing what the plans/process will look like beginning in 2014.

This guidance tells us that:

• DOI, with the assistance of the Illinois Department of Public Health (DPH), will initially review the plans and then by July 31, 2013 recommend the plan for certification to the federal government agency (called "CCIIO") to formally certify the plan.
• CCIIO will then be responsible for all contracting with the insurance plans and issuing the cost-sharing subsidies to people who enroll in the marketplace and purchase insurance. 
• DOI will conduct QHP oversight in 2014.
• Insurance plans must provide information about cost-sharing. For example, in 2014, deductibles in the small group market may not exceed $2,000 for self-only coverage and $4,000 for family coverage.
• All insurance plans must offer at least one plan at the Silver and Gold level of coverage and at least one child-only plan.
• Catastrophic plans can be offered but only to individuals under the age of 30 or is exempt from the Shared Responsibility Payment by reason of lack of affordable coverage or hardship.
• Rates must be the same for products sold inside and outside the Exchange
• The plans' networks must have "sufficient geographic distribution of providers" and must include providers that specialize in mental health and substance abuse services. In addition, as part of network adequacy, the guidelines specifies that plans must have Essential Community Providers (ECPs) that serve predominantly low-income, medically underserved individuals. (ECPs include FQHCs, Ryan White Providers and hospitals, among other entities. More information is available in HHS guidance here.) QHP issuers that do not include at least 20 percent ECP participation in network in the plan service area must submit an additional narrative justification in their QHP application. HHS has a non-exhaustive list of Essential Community Providers here.
  
• There are also requirements for health insurance plans to design their premium rates only on the basis on geographic location, tobacco use and age. Within these categories, the guidance sets parameters which limit the rates that can be charged based on ratios. For example, within the age category, insurers may not charge a (non-smoker) person who is 64 years old a rate that is more than 3 times as high as they charge a (non-smoker) person who is 21 years old. 

Lastly, insurers must file rates for review with the DOI and must submit a justification for a rate increase. Beyond these guidelines, however, the state does not have the authority to directly approve or disapprove of the rates insurance companies will charge. Many consumer advocates have recommended that the state grant the Department of Insurance more authority to review & deny insurance rate increases, as they do in other states. State legislation (SB 2344) is currently pending to do so. 

We'll report back in a few months to let you know additional progress on the QHP selection in Illinois in order to get ready for October 1, 2013 enrollment.
 
Stephani Becker & Stephanie Altman
Health & Disability Advocates 
Illinois Health Matters 

Obamacare Enters Its Big Year for Fighting Poverty

Obamacare, the Affordable Care Act (ACA), had its third birthday over this past weekend. So this is its first work week in its most important year. This is the year for the ACA’s heavy lifting, bringing affordable health coverage to 36 million uninsured Americans and ending discrimination against adults with pre-existing conditions, all effective as of January 2014. This is the year that the ACA becomes the biggest single measure in the fight against poverty in the last 50 years.
 
The ACA, of course, is usually discussed in terms of its impact on the health care system. And it is already doing a significant job on that front. In its birthday editorial, the New York Times aptly summarized the important contributions to reform of the health care system that the ACA has already produced:

• 6.6 million young adults covered through their parents’ health insurance (3 million of whom were previously uninsured);
• 71 million Americans received at least one preventive care service without co-payment (including 34 million older adults through Medicare);
• 17 million children protected from discrimination by insurance companies due to pre-existing conditions;
• 3 million more patients served by community clinics due to ACA-funded expansion;
• private premium increases dramatically slowed and $1.1 billion refunded to customers due to the ACA’s limit on premiums;
• 6.3 million seniors saved $6.3 billion in spending on drugs as the ACA fills in the notorious “donut hole” co-payment requirement in Medicare;
• growth of the overall cost of the health care system dramatically slowed; and
• promising improvements in health care quality. 

That is a substantial list of accomplishments; moreover, the health care system is due for its most important improvements in the coming year. The upcoming big changes, however, will have an impact that should be understood in more than just health care terms. The progress that will be made in the fight against poverty will be truly remarkable.  

Half of the gain in covering the uninsured will be directed at people in the deepest poverty in our country. Since Medicaid began in 1965, it has had a gap. It never offered coverage to people aged 19-64 who are not officially disabled and not caring for a child in their home. 

These are young adults leaving high school or college (whose parents do not have employer-supported coverage); empty nest parents whose children are over 18; tens of thousands of veterans not covered by VA health programs (over 12,000 would gain Medicaid coverage just in my home state of Illinois); chronically unemployed people with serious mental and physical impairments who are not officially disabled; many of the homeless; and others. The ACA will fill that gap in Medicaid , providing coverage to all with income under 138% of the Federal Poverty Line ($15,415 per year for an individual and $26,344 for a family of three) in the states that choose to take the federal money that the ACA offers them to pay for it.

For many people in poverty, health coverage not only means health, reduction in pain, and expansion of life expectancy, it also means employability and productivity and upward mobility. It can improve learning capacity. It reduces family stress. It can be a major factor in reducing family and community violence. It is a vast improvement in quality of life and quality of opportunity.

The ACA also ends the high cost for Medicaid beneficiaries of making more money. Currently, when a Medicaid beneficiary succeeds in the workplace and escapes poverty, there is a penalty: the loss of health coverage when earnings exceed allowed Medicaid levels. Starting in January, though, the Healthcare Marketplaces in every state will offer affordable private insurance coverage to replace Medicaid when earnings call for termination of Medicaid eligibility. This private coverage removes a barrier to upward mobility. It also acts as a net to keep workers in the middle class if they lose employer-supported insurance, when a health emergency might otherwise mean a free-fall into poverty. And it is there to provide coverage for budding entrepreneurs who want to try for the American Dream and start their own businesses, but who currently are blocked because they cannot risk losing either Medicaid or employer-supported coverage.     

Obamacare already fights poverty by helping seniors on Medicare make ends meet and by helping young adults make their way in the workforce by staying on their parents’ insurance. And in the coming year, at least in the states that implement it thoroughly, Obamacare will make its biggest inroads against poverty.  

John Bouman
President, Sargent Shriver National Center on Poverty Law

(This guest blog was originally posted here in the Shriver Brief) 

Sign On in Support of SB 34 - A State Run Exchange in Illinois

Illinois Senate Bill 34 establishes a robust, pro-consumer and pro-small business Health Insurance Marketplace in Illinois. The Health Insurance Marketplace will be the one-stop insurance shop for more than a million Illinoisans. SB34 ensures that the Marketplace is governed by a diverse board that represents women, small businesses, communities of color, labor, public health, people with disabilities, and consumers.  It is scheduled to be heard in subcommittee of the Senate Executive Committee today.

Please help signal broad support for this important health care bill by taking these 2 actions:

1. Sign on to the list of organizations supporting SB34

Click here to add your organization to the list of supporters for the passage of SB34.

2. Call the toll-free Marketplace Action line, 1-888-801-4426, and ask your state senator to cosponsor SB34!

If your state senator is already a cosponsor, please call him or her to thank them for their support. Here are the current co-sponsors:


David Koehler, Heather A. Steans, Don Harmon, Toi W. Hutchinson, William Delgado, Jacqueline Y. Collins, Michael Noland, Emil Jones, III, Julie A. Morrison, Steven M. Landek, Dan Kotowski, Patricia Van Pelt, Iris Y. Martinez, Mattie Hunter, Kimberly A. Lightford, Daniel Biss, Ira I. Silverstein, Thomas Cullerton, Terry Link, Melinda Bush, Donne E. Trotter, Bill Cunningham, Kwame Raoul, Napoleon Harris III

Please especially ask Senators Trotter and Clayborne and members of the Senate Executive Committee to pass SB34 out of committee.

SB34 must first pass out of the Governmental Operations Subcommittee and then the Executive Committee before going to a full vote.

Advocacy Materials:

You can find these materials and many others on our Health Insurance Marketplace page:

•     SB34 Fact Sheet
•     Health Insurance Marketplace Q&A
•     State Senator Co-sponsorship Form
•     Template for Co-sponorship request letter to senator
•     Template for Co-sponorship thank you letter
•     Multiple briefing resources

Jim Duffett
Campaign for Better Health Care

And Many Happy Returns: The Affordable Care Act Turns Three

The Affordable Care Act (ACA) is a historic law and its third birthday should be celebrated.
The law, each day, helps move the country from a 'sick care' system to a real health care system. Some of the lesser known but most important provisions of the ACA focus on preventing disease instead of treating people only after they become ill. Millions of Americans are already healthier because of the prevention portions of the law, including Community Transformation Grants (CTG), expanded coverage of preventive services and other measures focused on improving health in the ACA.

The law has also ensured that:

• Every new health plan, beginning in 2010, must include coverage of evidence-based, effective preventive services, such as screenings for type 2 diabetes, immunizations and mammograms, without co-pays;
• Seniors on Medicare receive many preventive services, starting January 1, 2011, with no co-payments - these services include annual wellness visits, cervical cancer screening, diabetes screening, mammograms and important immunizations such as for the flu and pneumonia; and
• The Prevention and Public Health Fund will invest $12.5 billion over 10 years (FY2013-FY2022) in locally-determined, evidence-based community prevention programs and will support public health job creation and training programs. The Fund will provide a coordinated, comprehensive, sustainable and accountable approach to improving the nation's health outcomes through the most effective prevention and public health programs.

One of the law's great prevention successes is the CTGs program -- one of the hallmark initiatives of the Prevention and Public Health Fund. CTGs provide communities with resources to focus on their top health priorities, including smoking cessation and obesity prevention.

In just three short years, the law has been an enormous benefit to Americans. In 2011, the Centers for Disease Control and Prevention (CDC) awarded $103 million in CTGs to 61 state and local public health or related organizations, and, in 2012, CDC funded CTG programs with $226 million, including approximately $70 million in CTG funding to 40 additional communities.

To commemorate the third anniversary of the Affordable Care Act, we at the Trust for America's Health (TFAH) released a story bank featuring stories of successful prevention initiatives in action from around the country. Many of the stories focus on CTG awardees and show how this new program, made possible by the ACA, is already helping to improve the health of Americans. TFAH's Prevention and Public Health Stories in the States story bank includes more than 50 profiles in 28 states, including:

• The launch of the first Accountable Care Community (ACC) in Akron, Ohio, which builds on the idea of an Accountable Care Organization. In 2011, the nonprofit organization Austen BioInnovation Institute (ABIA) brought together a wide range of 70 different groups to coordinate health care inside and outside the doctor's office for patients with type 2 diabetes, and received500,000 per year for 5 years for a capacity building CTG. The ACC reduced the average cost per month of care for individuals with type 2 diabetes by more than 10 percent per month over 18 months with an estimated program savings of3,185 per person per year. This initiative has also led to a decrease in diabetes-related emergency department visits.
• Oklahoma is using a CTG to work with a range of sectors to make healthier choices easier in the state. Nearly 70 percent of Oklahoma County's premature deaths are largely preventable, and the county spends about920 million every year to treat chronic disease. In September 2011, Oklahoma City was awarded a3.5 million CTG. Using a portion of those funds, along with additional outside resources, the Oklahoma City-County Health Department (OCCHD) created the "My Heart, My Health, My Family" program to provide prevention programs and services, specifically focused on cardiovascular disease. The CTG money will also support expanded walking and biking trails, a push to help schools offer healthy menu options and a physical education coordinator for city schools.
• Operation UNITE (Unlawful Narcotics Investigations, Treatment and Education) in Kentucky received a capacity-building CTG to help support this program which has delivered important results for a holistic, community-based approach to address substance abuse. UNITE was created a decade ago, however the CTG will help expand its work to support public health efforts aimed at reducing chronic diseases, promoting healthier lifestyles, reducing health disparities and controlling health care spending, and will serve 119 of the state's 120 counties. UNITE works to rid communities of illegal drug use and misuse of prescription drugs by coordinating treatment, providing support to families and friends and educating the public about the dangers of drug abuse.
• The West Virginia Department of Health is using CTG support to help local health departments in every county in the state implement targeted initiatives including: safe places in communities to work and play, Farm-to-School Initiatives to improve nutrition in school settings, Child and Day Care Center Nutrition Programs to educate and empower children to choose healthy lifestyles through physical activity and healthy food choices, and community coordinated care systems that link and build referral networks between the clinical system and community-based lifestyle programs so people can manage their health.

The ACA began a new era for public health. The law paves the way toward ensuring public health is no longer separated from the rest of the health care system. The ACA supports common-sense community approaches focused on connecting the care people receive in the doctor's office with opportunities to stay healthier beyond the doctor's office, where we all live, learn, work and play.

As the Affordable Care Act continues to benefit the country, in another year, we'll have an abundance of stories to share of communities turning their health around by focusing on preventing illness and thereby creating happy, healthy and thriving neighborhoods.

Jeffrey Levi, PhD

Associate professor of health policy, George Washington University

Executive Director, Trust for America's Health

(This article was originally posted in the Huffington Post blog here.)

Don't Restrict the Navigators!

The Affordable Care Act requires each Health Insurance Exchange to establish a Navigator program that will help people who are eligible to purchase coverage through the Exchange learn about their new coverage and enrollment options, including Medicaid, tax credits, and private insurance. In Illinois, the Navigator program will be paired with an In Person Assistor Program to help the 1.7 million uninsured residents in Illinois find coverage. The success of the ACA hinges on the ability of Navigators and In Person Assistors to reach eligible residents and provide culturally competent services. 

Two pieces of legislation currently being heard in the Illinois General Assembly - SB1194 & HB2608 – create barriers to this massive enrollment effort. The two pieces of legislation establish overly restrictive criteria for organizations and agencies that wish to serve as Navigators, making it more difficult for vulnerable populations to be connected with their new options for affordable health insurance coverage. For example, the bills require that Navigators be licensed by the state despite the fact that the Federal regulations specifically do not require licensing.

Additionally, SB1194/HB2608 are written to address a Navigator program operated by a state-based Health Insurance Marketplace. However, in 2014, Illinois will run its exchange in partnership with the federal government. Therefore, this legislation is unnecessary because HHS, not the Illinois Department of Insurance, retains ultimate authority over the Navigator grant process, including selecting Navigator grantees and awarding Navigator grants, and the approval of grantee activities and budgets.

Over a million Illinois residents will be eligible for new health insurance starting October 2013. For a successful marketplace, rather than putting into place restrictions that would deter and prevent community-based organizations from serving as Navigators, we should work to ensure that broad efforts are in place to connect these individuals with coverage. For that reason, we ask that you OPPOSE SB 1194 & HB 2608. See here for a fact sheet on the bills.

SB 1194 will likely be called for a vote in the Senate Insurance Committee on Wednesday, March 20th @ 5 pm. Don’t restrict the Navigators; please slip in opposition to SB 1194 and HB2608.

Kathy Chan, Illinois Maternal and Child Health Coalition
Nadeen Israel, Heartland Alliance for Human Needs & Human Rights
Ramon Gardenhire, AIDS Foundation of Chicago
Stephanie Altman, Health & Disability Advocates

Finding the Pot of Gold at the End of the Navigator Rainbow!

News that a new proposed rule on Navigators is under review at the Office of Management and Budget (OMB) hopefully means it won’t be long before we see model navigator training, conflict of interest and privacy standards. With any luck, release of the proposed standards should pave the way for the federal navigator grant solicitation.

The navigator funding opportunity announcement (FOA) will seek proposals from qualified organizations in the 33 states where the federal government will operate the exchange, including states that have opted for State Partnership Exchanges. Navigator grants in the 17 states (and D.C.) that are building their own state-based exchanges will not be included in this solicitation. The level of funding has not been disclosed but CMS officials have said the total amount will be allocated to states based on a formula that establishes a state minimum and factors in the number of uninsured people in the state. So there will be a larger pot of money for navigator grants in states with higher uninsured rates.

Any organization considering applying for a navigator grant should complete the registration process as soon as possible. Given the dwindling timeline, it’s not clear how long applicants will have to prepare their proposals but potential applicants – particularly those who have never applied for a federal grant – can register now. This doesn’t obligate you to apply but it gets the basics out of the way so you can concentrate on the substance of your response to the grant solicitation once it is announced. While applying for a federal grant might seem as daunting as finding a four-leaf clover, www.grants.gov provides step-by-step registration instructions in this checklist. There are five steps for registration and while most of the steps can be completed online the same day, Step 2 – registering with the System for Award Management (SAM) – can take up to two weeks.

A word of encouragement to small community-based organizations. Keep in mind that federal regulations require there to be at least two types of entities selected as navigators in any given state and one of those types must be a community or consumer-focused nonprofit organization. Capitalizing on the experience and passion in organizations that assist people with Medicaid and CHIP coverage is the best way to build a network of navigators to reach key populations of vulnerable and uninsured people and connect them to coverage. CMS officials have emphasized that all proposals – small and large – will be considered, so securing a grant could be a lot easier than catching a leprechaun!

If you want to learn more about navigators check out these two briefs:
“Countdown to 2014: Designing Navigator Programs to Meet the Needs of Consumers”
“Designing Navigator Programs to Meet the Needs of Consumers: Duties and Competencies”

For those of you who decide to apply for navigator funding, may the luck of the Irish be with you! Remember, registering now will put you five steps closer to the end of the rainbow.

Tricia Brooks
Senior Fellow
Georgetown University Health Policy Institute, Center for Children & Families

This blog was originally posted on Say Ahhh! a health care policy blog