Montana Health Insurance UpdatesMontana HealthCare Forum

Presented by

Commissioner Monica J. LindeenCommissioner of Securities and Insurance

Montana State Auditor

November 4, 2013

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2013 Montana Health Insurance Legislation

• Rate Review for Health Insurance—HB 87• Patient-Centered Medical Home Program—SB

84• Cancer Clinical Trials—SB 55• Network Adequacy for PPO’s—HB 544• Navigator/assister/producer training and

certification—HB 250

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State-based Rate Review – HB87

• The CSI introduced a bill to the 2013 legislature to create effective rate review authority for Montana.

• House Bill 87 (sponsored by Rep. Welborn) passed and is now law.

• For the first time, the Montana insurance commissioner has rate review authority.

• Montana has taken back rate review authority from the federal government.

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• In 2014, the ACA requires that adjusted community rating apply to the individual and small employer group markets

• Issuers may not vary rates for individuals or small groups based on health status or claims history

• Issuers must maintain a single risk pool and may vary rates based on: Age (3:1 maximum) Tobacco use (1:5:1 maximum) 4 geographic areas in Montana

Rate Review

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Benefits of Rate Review

• Montana consumers have already benefited: –One company lowered rates by 7 percent.– A second lowered rates by 22 percent. –A third company lowered rates by 66

percent.

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Patient-Centered Medical Homes – SB84• A Patient-Centered Medical Home (PCMH) is a

model of health care delivery that emphasizes primary health care, coordinated care and prevention.

• In the PCMH model, insurers pay an incentive based on quality of care, rather than quantity.

• SB 84 establishes standards and structure for a statewide PCMH program.

• SB 84 requires CSI to adopt rules to implement provisions of the law.

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Implementing the Montana PCMH Act

• Administrative rules were published at the end of September.

• Appoint the stakeholder council on November 8.• Establish a process for recognizing which accrediting

organizations meet Montana’s standards.• Begin qualifying practices and payers who meet the

decided standards in December.• Educate the public and promote PCMH across

Montana.• Working now to incorporate Montana specific

standards.8

Cancer Clinical Trials Senate Bill 55

• Passed by the 2013 Montana legislature to clarify coverage of routine costs for patients in approved clinical trials must be covered.

• Went into effect immediately upon passage.• Helps remove insurance uncertainties for doctors and

patients, allowing them to focus on fighting the disease instead of coverage for routine costs.

• Addresses confusion and inconsistency in coverage of routine care patients receive when undergoing a clinical trial.

SB55 Implementation• Note that the state law covers cancer only, but the ACA has a

similar provision that covers “all life threatening diseases.” (effective 1-1-14)

• CSI is still noticing insurance denials of routine care claims. When we explain the law to the company, they pay the claim.

• CSI will be issuing guidance to insurers soon to remind them of the law.

• The advisory council developed an Oncology Clinical Trial Treatment Notification Form.– The form is being finalized and is intended to be set as a statewide

standard for communication on trials between providers and payers.– CSI will continue education like today to the provider and payer community

to ensure the greatest benefit of the law to Montanans.

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Network Adequacy – HB544• A new network adequacy law in Montana was effective October 1,

2013. Most “network-type” health insurance plans, including dental and vision, sold in Montana are “PPO” plans. – The consumer’s cost-sharing is increased if he/she seeks

coverage from “out-of-network” healthcare providers. Consumer cost-sharing is substantially reduced or even eliminated if that consumer seeks healthcare services “in-network.”

• The new law says that a provider network is deemed adequate if it includes 90 % of the hospitals and 80 % of the healthcare providers in the state.

• Below that threshold percentage, the commissioner may “determine” a network to be adequate.

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Network Adequacy cont.• Below that level, a maximum differential is applied: no more

than 25 % cost-sharing difference that the consumer pays for out-of-network services.

• The commissioner will disapprove a network plan as “misleading” if there is no viable network.

• Cost-sharing differences between in and out-of-network are significant—as much as four times higher. Consumers should always check the insurer’s list of in-network providers before they choose a health plan.

• Many of the benefits of the ACA are based on “in-network” costs only.

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Assistor State Certification– HB250• All navigators, Certified Application Counselors

(CACs), and Certified Exchange Producers (CEPs) must complete federal and Montana-specific training be certified.

• CEPs must complete federal and state training to sell products through the marketplace.

• CSI developed state-specific training materials. Navigators must pass a background check and take a test.

• CSI has a list of all certified navigators, CACs, and agents on www.montanahealthanswers.com.

Navigators and CACsThe ACA allows for two new consumer

assistance roles• Navigators – contracted through grants from HHS,

responsible for performing outreach and education, as well as enrollment assistance

• Certified Application Counselors – not paid by exchange or federal grants—only offering enrollment assistance• Intended for current employees of medical providers and

community groups

Navigators and AgentsSimilarities and Differences• Both navigators and agents help consumers by

providing marketplace enrollment assistance.• Navigators operate only within the Marketplace.• Unlike agents, navigators cannot be compensated in

any way by insurers.• States cannot require that navigators be licensed

producers, but they do need state certification and training.

• Navigators and CACs may NOT recommend specific insurance products.

HB250 Implementation• In addition to their federal training, CSI

required an online state training for all 3 types of assistors.

• CSI created to 90 minute webinars, both were required for CACs; one was required for Navigators.

• Weekly calls with Navigator groups.• CSI is a continuous resource for CACs and

Navigators.• Ongoing regulation of all 3 roles. 16

Certified Assistors as of October 25, 2013

• Certified Application Assistors: 69• Navigators: 26• Certified Exchange Producers: 291

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Montana Specific Training Included:• Montana specific information on Medicaid and Healthy Montana Kids

eligibility• American Indian ACA benefits• Montana specific privacy laws• Unlicensed producer activity and the consequences• Background information on plan design structure and how to choose a

plan• Deductibles and other cost-sharing• Financial and health considerations• Network Adequacy• Prescription drug formulary• Summary of Benefits and Coverage

• Multi-State Plans• Autism and Mental Health Parity• Stand-alone dental plans• How to help people who aren’t eligible

Affordable Care ActMarketplace

• Montana’s federally built, federally maintained Marketplace website is not working properly.

• www.montanahealthanswers.com, visited by more than 11,000 individual Montanans.

• We’ve answered nearly 1,000 questions from our Ask Away site.

• Our office has hosted dozens of town hall events to explain the law.

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Adjusting to Marketplace Problems

• Continue to do outreach and education. • Work with assistors to adapt to problems and help

consumers.• Answer questions through the website.• Montana website made more shopper friendly with a

calculator and charts on plan structure and cost break down for people to view without having to go to healthcare.gov.

• I met with an HHS official just last week to tell my concerns and find out when a fix is expected.

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Montana is a Plan Management State for the Marketplace

• The CSI works with the federally facilitated marketplace to alleviate duplication and save consumers time and money.

• This coordination helps preserve the state regulation of health insurance.

• CSI’s plan management duties includes:– Recommending qualified health plans to the federally

facilitated marketplace.– Using rate review authority to review health insurance

rates and their benefits.– Monitoring insurance companies for compliance with state

and federal law.

Questions?

Call my office 1-800-332-6148Or visit www.csi.mt.gov

www.montanahealthanswers.com