CMSA Today - Issue 8, 2012 - (Page 13)

CMSA Case Management and the Law Preparing for the Exchanges N BY GARRY CARNEAL, JD, MA ow that the Supreme Court has issued its decision upholding the key provisions of the Patient Protection and Affordable Care Act (PPACA),1 state governmental agencies are moving forward with the task of implementation, including the creation of state health benefit Exchanges for individuals and small group employers. A centerpiece of the federal healthcare reform law, all case managers should be familiar with the various types of Exchanges set up in areas where they live, or in other states where they are coordinating care for their patients/clients. Under the federal Exchange model, many details need to be worked out between U.S. Department of Health and Human Services (HHS) and the local state governments. For example, a federally-run Exchange will need to operate concurrently with the existing state-regulated private health insurance market. This necessity will likely create some challenges as two sets of government officials will be approving and/or setting rates and benefits and creating expansive sets of rules, not all of which will be congruent. Additional questions remain about the structure of the federally-run Exchange. Many of these questions should be answered when the final federal Exchange rules are published by HHS. Another consideration is whether there is adequate funding to run both the federal and state-based Exchange system. For example, the funding authorization for federally-operated Exchanges was not included in the final version of PPACA. Once the structure and funding issues are addressed in each jurisdiction, the Exchange system will assume a very important role in helping to expand coverage to underinsured and uninsured populations. Functions include: • Serving as a purchasing cooperative that promotes transparency • Creating a qualified health plan certification process • Standardizing benefit offerings (including essential health benefit requirements and gold/silver/bronze levels) • Promoting informed decision-making through a consumer website/online enrollment portal • Supervising an electronic enrollment process, and • Implementing a process to distribute premium subsidies. Some are concerned this new administrative layer of oversight will raise the cost of insurance dramatically for most Americans as the federal and state governments need to raise taxes to help pay for this system. Others worry this might disrupt existing insurance markets – especially the private sector – through adverse risk selection. Many have studied the successes and failures of the Massachusetts and Utah Exchange models that pre-date PPACA to identify learning points about what these states did correctly and where they had challenges. Many public policymakers are hopeful that the PPACA-enabled Exchanges will fill some existing gaps in the current U.S. health insurance system. Case managers should continue to track key PPACA developments, including the Exchanges, going forward. continued on page 18 CMSA TODAY 13 Exchanges can take on several different configurations. Under PPACA, states are encouraged to establish one or two Exchanges in their respective jurisdictions. Options include: • Individual/Non-Group • Small Business Health Options Program (SHOP) • A blended model that combines both the Individual and SHOP options. State Exchanges must be certified and operational by October 1, 2013 in preparation for the January 1, 2014 go live date. Individuals and small group employers with less than 100 employees will be able to access health insurance through the state Exchange system. Beginning 2017, state health insurance SHOP Exchanges may be able to expand eligibility to large employers with more than 100 employees. Progress among states in setting up the Exchanges varies widely. The National Conference of State Legislatures (NCSL) is tracking the progress on the association’s website at Currently, 16 states are moving forward with Exchanges – including California, Colorado, Connecticut, Hawaii, Indiana, Kentucky, Maryland, Massachusetts, New York, Nevada, Oregon, Rhode Island, Vermont, Utah, West Virginia, Washington (and the District of Columbia). At press time, Illinois and Pennsylvania had pending legislation to create a statebased Exchange system. If a state is unable to create an Exchange, or refuses to do so, PPACA requires the federal government to step in and implement a federally-facilitated Exchange. Currently, 10 states are not moving forward with state-based Exchanges – including Alaska, Florida, Louisiana, Maine, Michigan, New Hampshire, Ohio, South Carolina Texas, and Wisconsin. Twenty-two additional states are undecided or are leaning toward opting out of broad health care reform. In these cases, the establishment of federal Exchanges may be the outcome. States that default to a federal Exchange will have several options in terms of the structure of the Exchange. One is to form a joint venture with the federal government and be responsible for some of the operational aspects of the Exchange. Another option is to allow the federal government to run the entire Exchange, but under this scenario local support will be needed. 1 2 See the last legal column, where the results were summarized. Type in “NCSL Exchanges” in Google to get to the tracking page or see Issue 8 • 2012 • DIGITAL

Table of Contents for the Digital Edition of CMSA Today - Issue 8, 2012

President's Letter
Transitions in Care
Passion in Case Management
Patient Assistance Programs
Association news
View from Capital Hill
Case Management and the Law
Ethics Casebook
Mentoring Matters
CMSA Corporate Partners
Index of Advertisers

CMSA Today - Issue 8, 2012