Posted by AzBlueMeanie:
Elections have consequences, and the most important consequence of the 2012 election is that the Affordable Care Act (aka "ObamaCare") is the law of the land and will now be fully implemented.
The Obama administration will allow states additional time to plan health insurance exchanges, and to set up the marketplaces at the heart of the Affordable Care Act (ACA). For hurried states, Obama administration extends health law deadlines:
States now have an extra month to send the federal government “blueprints” for how they will have the health exchange up and running by 2014, according to a letter Health and Human Services Secretary Kathleen Sebelius sent to governors Friday. They must still inform the Obama administration whether they plan to set up an exchange by the original deadline of Nov. 16. Planning documents must follow by Dec. 14.
Many states have already decided they will not build the insurance marketplaces, leaving the task to the federal government.
The governors of Florida, Virginia and Kansas announced Thursday they would take this route. As many as 17 states are expected to have the federal government run their exchanges, according to an analysis from consulting firm Avalere Health.
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Sebelius wrote to governors that the agency had “heard from many states that additional time would allow you to submit a more comprehensive, complete Blueprint application for your Exchange.”
“We are committed to providing you with the flexibility, resources, and technical assistance necessary to help you achieve successful implementation of your state’s Exchange,” she wrote.
States also have the option of pursuing a “partnership” exchange. Under that model, the state and federal governments would each take partial responsibility for running parts of the insurance marketplace.
States pursuing that model must notify the federal government in just over three months, by Feb. 15.
The Obama administration must certify that all states planning to administer their own exchanges have made sufficient progress by Jan. 1. Next October, the marketplaces will need to launch for open-enrollment periods.
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“If states don’t make this decision in the next 15 to 30 days, it’s going to be really hard to catch up,” said Sam Gibbs, senior vice president of sales at eHealthInsurance, which is helping states build insurance exchanges. “That’s why Sebelius is saying, ‘You can give me your plans later, but I still need to know which direction you’re going.’ ”
The extended deadlines will not affect the overall implementation timeline: Health insurance exchanges are still slated to launch at the start of 2014.
Community Catalyst (communitycatalyst.org) is "a national non-profit advocacy organization working to build the consumer and community leadership that is required to transform the American health system." Its first priority is quality affordable health care for all. Community Catalyst has a good quick explanation of the health insurance plans to be offered through the exchanges that will be set up under the ACA. Essential Benefit Package - Health Insurance 101:
The Affordable Care Act (ACA) makes a number of changes to private health insurance plans. One important protection is the establishment of a package of essential health benefits.
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The details of what is included in the essential health benefits package will be determined by the Secretary of Health and Human Services (HHS) in a future regulation, but the ACA lists a set of core, federally-required benefits and describes the health plans which will not be required to offer these essential health benefits.
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The essential health benefits are intended to mirror those provided under a typical employer-sponsored health plan. The HHS Secretary must define a package that includes, at a minimum:
- Ambulatory patient services, such as doctor's visits and outpatient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
While the ACA requires coverage for each of these categories, the law does not define the specific services that must be covered or the amount, duration, or scope of services. The HHS Secretary will define the specific benefits within each of these categories and will be able to update the definition over time to address gaps or respond to changing medical practices in the future.
In defining the essential benefits package, the HHS Secretary must decide not only which health services to include, but also how much discretion to leave to insurers in coverage decisions. For example, if the Secretary determines that physical therapy to treat lower back pain is a covered benefit, she could determine the minimum number of physical therapy sessions that must be covered to treat the condition, or she could leave that to the discretion of the insurers.
Currently, many insurers must cover certain services as requirements of state law. The ACA allows states to continue to mandate health benefits. However, going forward, if the mandated benefits are not included in the essential health benefits defined by the HHS Secretary, states will have to pay for any increased premium costs that result from those mandates. HHS will likely determine this process in future regulations.
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The ACA links the essential health benefits package to limits on cost-sharing. So health plans that are required to provide essential health benefits will also be required to limit the amount consumers will have to pay out-of-pocket. Specifically, health plans will be prohibited from requiring consumers to pay annual cost-sharing that is greater than the limits for high deductible plans linked to health savings accounts. Currently, those limits are $5,950 per year for individuals and $11,900 per year for families. In addition, small group plans must limit deductibles to $2,000 for individual coverage and $4,000 for family coverage. As with all health plans under the ACA, there is no cost-sharing for certain preventive health services recommended by the United States Preventive Services Task Force.
Within these allowable limits, all health plans except grandfathered or self-insured plans will be required to provide consumers with specified levels of coverage, determined by the plan's actuarial value. The levels of coverage are set as percentages of the actuarial value of a plan that covers the full essential benefits package with no cost-sharing. These levels are represented as Bronze, Silver, Gold, and Platinum.
Starting January 1, 2014, the ACA requires individual and small group plans to include all essential health benefits, limit consumers' out-of-pocket costs, and meet the Bronze, Silver, Gold and Platinum coverage level standards - however, grandfathered and self-insured plans will be exempt. Large group plans (in most states, groups with more than 50 employees) are required to meet the cost-sharing limits and the benefit levels, but are not required to provide the full scope of benefits in the essential benefits package.
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Beginning January 1, 2014 |
Must Provide Essential Health Benefits |
Must Limit Cost Sharing and Deductibles |
||
|
Health Plans in Exchange |
Small Group |
Yes |
Yes |
|
|
Non-Group |
Yes |
Yes |
||
|
Other Health Plans |
New Plans |
Self-insured |
No |
No |
|
Large Group |
No |
Yes |
||
|
Small Group |
Yes |
Yes |
||
|
Individual |
Yes |
Yes |
||
|
Grandfathered Plans |
Self-insured |
No |
No |
|
|
Large Group |
No |
No |
||
|
Small Group |
No |
No |
||
|
Individual |
No |
No |
||
The Essential Benefit Package - Health Insurance 101 page links to a menu of related topics of interest.
The National Conference of State Legislatures (NCSL), which many state legislatures rely upon, has a more detailed summary for policy wonks at American Health Benefit Exchanges.
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