__________________________________
Lisa Summers, CNM, DrPH
Peter McMenamin, PhD
Department of Nursing Practice & Policy
State Health Insurance Exchanges:
THE CRITICAL ROLE OF NURSES & NURSING
Acknowledgement
Laura Brennaman, MSN, RN, CEN
Doctoral Fellow
RWJF Nursing & Health Policy Collaborative
University of New Mexico
Overview
State Health Insurance Exchanges 101
– What are they?
– Why should you be engaged?
Stories from the States
– Colorado
– Maryland
– Mississippi
Questions and Discussion
President’s address June 28, 2012
if you’re one of the 30 million Americans who
don’t yet have health insurance, starting in
2014 this law will offer you an array of quality,
affordable, private health insurance plans to
choose from. Each state will take the lead in
designing their own menu of options…
Once states set up these health insurance
marketplaces, known as exchanges, insurance
companies will no longer be able to discriminate
against any American with a preexisting health
condition. They won’t be able to charge you more
just because you’re a woman. They won’t be able to
bill you into bankruptcy. If you’re sick, you’ll finally
have the same chance to get quality, affordable
health care as everyone else. And if you can’t afford
the premiums, you'll receive a credit that helps pay
for it.
What is an Exchange?
Portals for individuals & small businesses to
buy affordable & qualified health plans.
Intended to:
– Enhance competition in the health insurance
market
– Improve choice of affordable health insurance to
individuals
– Give small businesses the same purchasing clout
as large businesses.
Timeline for Exchanges
Federal government will assess states’
readiness to operate Exchanges January 2013
Scheduled to start open enrollments in
October 2013.
Insurance effective dates beginning January 1,
2014.
Consumer assistance tools
Toll-free call center
In plain language
That are accessible and
timely manner
interpretive services for
people who have
limited English
proficiency
Up-to-date website
standardized
comparison of all
qualified health plans
Essential Health Benefits Package
Ambulatory patient
services
Emergency services
Hospitalization
Maternity & newborn
care
Mental health &
substance use disorder
services, including
behavioral health
treatment
Prescription drugs
Rehabilitative &
habilitative services &
devices
Laboratory services
Preventive & wellness
services & chronic
disease management
Pediatric services,
including oral &
vision care
Plan Levels & Cost Sharing
Insurers contribute
60% of costs of EHBP
for Bronze plans
70% of costs of EHBP
for Silver plans
80% of costs of EHBP
for Gold plans
90% of costs of EHBP
for Platinum plans
Comparing Plan Value in the Exchange
Consumers want it to be easy to compare
premiums and benefits covered.
Premium costs comparison
Standardized actuarial rating (metal level)
Quality ratings by accreditation agencies
Medical loss ratios
Up-to-date provider directories
Column1
Administrative costs
Medical Loss Ratio
(MLR)
The MLR
requirement is
80% for plans
sold inside the
Exchange
Health care services and
quality improvement
20%
80%
Navigators
Assist Exchange users to
select a health plan
Conduct public
education activities to
raise awareness about
the Exchange
Refer complaints or
problems to
appropriate agencies
for resolution.
Seamless Streamlined Process
“one-stop shopping” where people with
lower and moderate incomes can learn if
they qualify for Medicaid
CHIP benefits
Premium subsidies
Tax credits for eligible small benefits
ANA Advocacy
APRNs should recognized as primary care
providers in qualified plans
Nurse Managed Health Clinics, School-Based
Health Clinics, and Free Standing Birth Centers
should be Essential Community Providers
APRNs should be team leaders in Patient
Centered Medical Homes
Nurses should be on the governing boards of
State Health Insurance Exchanges
Progress on Exchange
Development
From Kaiser Family Foundation
Updated April 13, 2012
Offers sufficient choice of providers in-network
and out-of-network while assuring reasonable
access to quality primary and specialty care.
The National Association of Insurance
Commissioners (NAIC) Model Act for network
adequacy includes all types of licensed health
care professionals, including APRNs.
CMS affirms the network must assure that all
services will be available without unreasonable
delay
Network Adequacy
APRNs Provide
Essential Benefits
All four APRN
roles need to be
included in
health
Exchanges
Ambulatory Services
Maternity & Newborn Care
Services during
Hospitalizations
Chronic disease management
Mental health & substance
use disorder services
Essential community providers are those
healthcare delivery providers that serve
predominantly low-income, medically
underserved individuals.
They are to be included in qualified plan
networks as long as the provider accepts
the generally applicable payment rates of
the plan.
Essential Community Providers
Essential Community Providers
Should include
Nurse-managed health centers
School-based health centers
Freestanding birth centers
Provider
Directories
Should list all
credentialed
providers
• Online
version
• Print version
Nurses and state associations will need to monitor
the evolvement of Exchanges in their states to
deliver the evidence of quality, improved access,
and cost saving available through APRN directed
primary care
ADVOCACY AT THE STATE LEVEL
Resources
ANA Issue Brief, State Insurance Exchanges:
The Critical Role of Nurses and Nursing is
available on line.
http://nursingworld.org/statehealthinsurance
exchanges
It includes links to good sites for keeping
abreast of developments.
Upcoming HHS Forums (email invitation 7/17)
Stories from the States
Colorado
Fran Ricker, Executive Director, Policy Director and
Lobbyist, Colorado Nurses Association
Maryland
Robyn Elliot, Lobbyist, Maryland Nurses Association
Mississippi
Teresa Malone, Executive Director, Mississippi Nurses
Association
For more information: NursingWorld.org