Update on SB 1194 (The Insurance Navigator Act)

Starting October 2013, an estimated 1.6 million Illinois residents will be eligible for new and affordable forms of public and private health insurance coverage under the Affordable Care Act. But the overwhelming majority of the newly eligible have no idea how to access these options. Many Illinoisans will need more information and guidance through the enrollment process.

The Affordable Care Act requires each state’s Health Insurance Marketplace to establish a Navigator Program that will guide these individuals through their new coverage and enrollment options. These Navigators will serve an important role in ensuring that individuals benefit from the ACA.

On January 30th, the potential efficacy of the Navigator program was threatened by the introduction of Illinois Senate Bill 1194, which would create overly restrictive criteria for organizations applying for and performing navigator functions.

Here are the issues with SB1194 (as it was introduced):

• SB1194 placed unnecessary restrictions on Illinois Navigators and In-Person Assistors, making it more difficult for low-income and hard-to-reach populations to connect to the application assistance that they need.  
• Illinois is currently preparing a Navigator training and oversight system that makes SB 1194 unnecessary. 
• Federal law already mandates some of what is outlined in SB1194, such as prohibiting Navigators from recommending specific insurance products. Once again, SB1194 is unnecessary.  
• Language in SB1194 prohibited Navigators from facilitating enrollment in a Federally Qualified Health Plan, (QHP), one of the five Navigator duties already specified by the ACA.

Consumer advocates and community based-providers recognized these issues, and successfully lobbied state Senators to make changes in the bill.

Here’s what changed:

• SB1194 now includes the Navigator duties as spelled out in the ACA.
• SB1194 now includes a certification, instead of a licensure, requirement.
• SB1194 excludes all prior language that restricted Navigator duties, (such as the ability to facilitate enrollment in a QHP).
• SB1194 is now in alignment with Federal regulations regarding the training and responsibilities of Navigators.
• SB1194 now allows for the training of Certified Application Counselors, (another type of Navigator not directly compensated by the Exchange), to be defined at a later date. This means that CAC training will align with federal guidelines.

What’s happening now?

These amendments were filed on April 22nd, passed in the Senate on the 24th, and were referred to the House Rules Committee earlier today. You can follow SB 1194’s status here.Thanks to all of the advocates for raising your voices against restricting the navigators in this new health care system.

Nadeen Israel
Policy Associate, Heartland Alliance for Human Needs & Human Rights

Please contact Nadeen at nisrael@heartlandalliance.org for more information on SB1194.

The “Rate Shock” Myth

As Affordable Care Act opponents continue grasping at straws to find fault with the law, an assertion perpetuated by the insurance industry that the ACA’s coverage expansions will significantly increase premiums has gained prominence. Lately, many insurance industry-funded studies and the resulting news coverage of them have focused on the potential for “rate shock” for the young and healthy, fear mongering young adults and others into thinking their rates will skyrocket come 2014. None of these reports address all of the protections written into the bill to prevent steep rate changes and many fail to accurately represent the true scope of benefits and costs. Community Catalyst has prepared this fact sheet to help cut through some of the confusing arguments swirling around.

Very few people will be affected by significant rate changes. To give a sense of how small this number is, more than half of employed 19-44 year-olds were covered through their employers. Of those who are not offered insurance through an employer, 92 percent of young adults expected to enroll in individual plans with subsidies through the Exchanges would not be subject to premium increases. This is not to say that nobody will experience rate changes, but it is important to understand the relative impact of increases and the small number of people affected.

Rate changes will primarily impact young men between the ages of 19-27, who have incomes higher than 400 percent of the federal poverty level (more than $45 thousand per year) and are not covered through their employers. And even these individuals will only experience moderate changes – on average an increase of 10-13 percent compared to current non-group rates, according to the Congressional Budget Office.

Most importantly, the ACA means everyone will gain increased value per health care dollar through better benefit packages and limits on how much patients can pay out-of-pocket. New plans will be required to meet certain standards of benefits, including covering maternity, mental health, prescription drug coverage, and charging no co-pay or deductible for preventive services including cancer screenings and contraception. These new standard benefits ensure that consumers will get greater value and better protections than many plans currently provide. Young adults will also have the option of enrolling in a catastrophic coverage plan that covers the same benefits but offers lower premiums with a higher deductible.

The law also makes the system fairer across gender and age groups. Currently, insurers commonly charge women more than men, simply because they have the potential to incur more costs through maternity care. This unfair practice costs women in the private market approximately $1 billion per year, but is outlawed under the ACA starting in 2014. Similarly, insurers are allowed to charge older adults significantly higher rates. The ACA places limits on this practice so older adults can only be charged a maximum of three times as much as younger adults. This change reflects a more accurate approximation of the health cost differences between young and old, correcting years of overcharging adults for their health care services. Finally, the ACA ends discrimination against those who have preexisting conditions. This is not irrelevant for young adults, since 16 percent of 16-24 year olds have preexisting conditions and either are unable to gain coverage or are pay higher rates because of their medical history.

When it all shakes out, the benefits of the ACA for young adults far outweigh any costs. The impact of premium changes will be limited, will help make the health insurance system fairer, and will ensure consumers get more bang for their buck.

Sarah Gordon, Private Insurance Team Intern
Community Catalyst

(Blog originally appeared here on the Health Policy Hub)

The “Culture of Coverage:” How Illinois is making the Health Insurance Marketplace Work

On March 29th, Illinois submitted an outreach and enrollment plan to the federal government, a requirement for all states participating in a state-federal partnership health insurance exchange. In the proposal, the marketplace team explains that they plan to treat outreach and enrollment like a political campaign, working not to elect a candidate but instead to introduce a new “health culture” to Illinoisans who have traditionally been excluded from coverage. The campaign will launch full-force in July in order to address skepticism and the general lack of awareness around the Affordable Care Act before enrollment begins on October 1st of this year.

Campaign values:
Illinois faces a variety of challenges, including limited English proficiency and low literacy rates, which make the task of reaching and enrolling certain populations of residents difficult. 78% of uninsured adults and 83% of the Medicaid population are unaware of insurance options under the ACA. To insure that Illinois is successful in promoting awareness of the Affordable Care Act, the marketplace team’s work will be guided by the following principles:

1. Promotion of a State-wide Culture of Coverage; 
2. Empowerment of Community-Based Organizations and Stakeholders; 
3. Metric-Focused Encouragement of Enrollment; 
4. Promote Health Care as a Value; and 
5. Build a Strong and Trusted Reputation Among All Residents. 

Campaign strategy:
Based on the assumption that many Illinoisans aren’t aware of their options, the marketplace team will hire a professional marketing firm by the end of May. This firm will work to create a cohesive brand that speaks to target populations while establishing the Illinois marketplace as a trusted entity and something that residents will want to participate in. This media campaign will consist of television, print, outdoor, direct mail, online, and social media advertising.

The field program:
While the exchange branding is no doubt important, the marketplace team recognizes that empowering community partners to assist in the outreach and enrollment process may be the most effective way to achieve a “culture of coverage,” as these community partners are already known and trusted entities. This collaboration, titled the “field program,” will focus on the “4 E’s:” Engage, Empower, Educate, Enroll.

Staffing structure:  
Illinois will be divided into 8 “Outreach Regions,” which will be constructed geographically and by information around where the uninsured in Illinois reside. Each region will be headed by an Outreach Coordinator, who will report to the Director of Outreach & Consumer Education.

In order to assist with enrollment, three categories of assisters will be established. Similar training must be undergone in order to qualify for each category. The assister categories are as follows: 

1. Navigators: part of a federally-run assistance program 
2. In-Person Counselors: a state program that will coordinate with Regional Outreach Coordinators. Selected entities are expected to spend one year as assisters. 
3. Certified Application Counselors: Additional national funding for individuals who aren’t funded through grant money.

It’s coming…
The marketplace team is already working hard to make sure the health insurance marketplace works in Illinois. In the meantime, click here to check out the full Illinois Health Insurance Marketplace Outreach & Education Plan!

Kathryn Bailey
Health & Disability Advocates

Will Illinois Have Enough Family Physicians Beyond 2014?

Do we have enough physicians to care for newly insured patients seeking care starting Jan. 1? Some will be covered by Medicaid; some gain coverage through the insurance marketplace; and others turning 65 join the ranks of Medicare. The Illinois Academy of Family Physicians believes that we are ready for 2014 – but are not prepared for future demand for primary care.

Illinois currently has the capacity to care for more than 5.3 million Medicaid patients, with more than 5,000 primary-care providers participating in team-based medical homes. When patients have a regular primary-care physician, they get the care they need to avoid costly emergency room visits and hospitalizations. Connecting new Medicaid patients with a family physician ensures they get the right care at the right time in the community setting, at a much lower cost. Otherwise uncontrolled chronic illnesses can develop into costly – and preventable – hospitalizations, which drives up medical costs for everyone.

Illinois has 11 medical school campuses. This year, only 9 percent of 1,089 doctors graduating from those medical colleges chose family medicine, according to IAFP data. And only one-third of that 9 percent — 35 people — will do their residency training in Illinois; the rest will leave for other states. Family physicians are the only physicians trained to care for all ages, both male and female.

Illinois should worry about the future of our state's primary-care physician workforce. Simply stated, too many physicians trained here choose to work in other states, and Illinois is not training enough primary-care physicians.

A NATIONAL PROBLEM, TOO

According to the American Association of Medical Colleges workforce data book, Illinois ranks 20th in the nation with 95 primary care physicians per 100,000 residents. As a nation, we are facing a staggering shortage of primary care physicians. So being in the middle of the pack should not be interpreted as a positive sign.

A 2010 study led by family physician Russell Robertson (now dean of Chicago Medical School) examined new physicians' plans for practice and the reasons for their choices. Almost one-half of graduating Illinois residents and fellows leave the state to practice elsewhere. While the primary reason for do so is for family, the medical liability climate is a major consideration for those who leave Illinois to practice.

How can we turn the tide? Medical schools need admission policies favoring students willing to practice in Illinois. We also must address medical school debt that keeps many from entering primary care. Those physicians should get loan repayment or loan forgiveness incentives to practice in areas in need of primary-care physicians. As well, the income gap between primary-care and specialty physicians must be narrowed. Medicare and Medicaid must take the lead and pay primary-care physicians in accordance with the quality care and coordination services they provide, and private insurers must support primary care.

Making primary-care practice a priority ensures that every Illinoisan entering the health care system has a medical home to care for them. A future without enough family physicians will leave patients without a medical home and on the doorsteps of emergency rooms instead.

Dr. Carrie E. Nelson is president of the Illinois Academy of Family Physicians, based in Lisle.

This article was first published in Crain's Chicago Business

Great News for the People of Illinois...Now What?

Yesterday, Governor Quinn announced that Illinois was awarded a $115 Million grant for its Health Insurance Marketplace (the online portal to enroll over a million adults and children into quality health plans). A large portion of this federal funding will pay for outreach activities and consumer assistance during the push to enroll the uninsured beginning on October 1 of this year.

This is great news for the people of Illinois.

With October 1 less than six months away, we need these federal funds to help get the word out about the availability of new insurance coverage options. According to Enroll America's research findings, the  majority  of  uninsured Americans  don’t  know the  health  reform  law  will  help  them:

• 78% of  the  uninsured  don’t  know  about  the new  health  insurance  exchanges  
• 83% of  people  who  could  be  eligible  for  the new  Medicaid  expansion  don’t  know about  it.  

Tremendous amount of work needs to get done to tell people about the new options and enroll them into a plan. 

Here's a timeline of what needs to happen to be ready by October 1, 2013. Since Illinois is running its exchange/marketplace in partnership with the federal government, we need to be mindful of activities by both the feds and the state:

Already Happened:

• Illinois Marketplace Team Selects Training Vendor (UIC/Public Health)
• Marketplace Team Releases Outreach & Education Plan & Conducts Outreach to Encourage Navigator & In Person Assister (IPA) Applications. (Read this fact sheet to learn about the different Consumer Assistance Entities needed).
• Marketplace Team Receives Establishment Grant Funding
• Illinois Marketplace Team Releases RFP for Media and Marketing Outreach Strategy.
• CMS Releases Proposed Standards for Navigators and In Person Assisters (see here for a good summary)
• Federal Government Releases Navigator RFP (Just released today, April 9, 2013; due June 7,
  2013; Expected Award Date - August 15, 2013). 
• Advocates create the Illinois Consumer Assistance Matchmaking Spreadsheet to find partners in either the federal Navigator grant or the (yet to be released) Illinois Assister RFP.

Spring 2013:

• Marketplace Team Issues RFP/Grant Application for IPA entities
• Marketplace Team Approves IPA Training Materials
• Marketplace Team selects firm for Media and Marketing Outreach Strategy (UPDATE: On 7/12/13 Fleishman Hillard is selected)

Summer 2013:

• Federal Government Selects Navigator Entities (Due date for application: June 7, 2013)
• Marketplace Team Selects IPA entities (see list here) 
• Federal Government Takes Applications for Certified Application Counselors (sign up here)
• Navigators, IPAs, Certified Application Counselors (CACs) Receive Training and Certification.
• Media placement begins

October 2013 and beyond:

• Navigators, IPAs & CACs Assist Consumers during Open Enrollment
• Navigators, IPAs & CACs Provide Post-Enrollment Assistance & Assistance during Special Enrollment Periods
• Program Oversight Conducted By Marketplace Team and Federal Gov’t.

The timeline is tight and we need all types of entities (community based organizations, hospitals, health departments etc.) to help with enrollment.

If you have any questions about  what this means for you or your organization, please don't hesitate to contact us at info@illinoishealthmatters.org.

Stephani Becker
IHM Project Director

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)