1. Health Insurance and
You
Virginia State Corporation Commission
Bureau of Insurance
This presentation is for general educational purposes only. Nothing in this
presentation is intended to be an opinion, legal or otherwise, of the State
Corporation Commission or the Bureau of Insurance, nor should it be
construed as an endorsement of any product, service, person or
organization mentioned in this presentation.
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2. Objectives
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Overview of Virginia SCC/Bureau of Insurance
Describe key provisions of recent health insurance changes
Discuss coverage options/changes in 2014
Describe the Bureau’s role in Plan Management functions of
the federal exchange (Health Insurance Marketplace in
Virginia)
• Describe how Bureau of Insurance can provide assistance
• Other resources
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3. Bureau of Insurance
(BOI)
The BOI licenses, regulates, reviews forms and rates for approval,
investigates and examines insurance companies, agencies and
agents on behalf of the citizens of the Commonwealth of Virginia.
The BOI Insurance also registers, examines and investigates (title)
real estate settlement agents and agencies.
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4. BOI’s Regulatory Mission
To ensure that citizens of the Commonwealth are provided with
access to adequate and reliable insurance protection; that the
companies selling insurance are financially sound to support
payment of claims; that the agents selling insurance are qualified
and conduct their business according to statutory and regulatory
requirements, as well as acceptable standards of conduct; and
that the insurance policies are of high quality, are understandable
and are fairly priced.
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5. Affordable Care Act (ACA)
• Comprehensive federal health care law enacted on March 23,
2010
• Various provisions effective at differing dates
• Various state laws were enacted to conform state law to a
number of requirements within the ACA
• Other nonconforming areas, such as operating the state’s
health benefit exchange in Virginia, remain the sole province
of the federal government
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6. Current Virginia law
• Lifetime dollar limits on essential health benefits (EHB) prohibited
• Annual dollar limits on EHB restricted for most plans
• Pre-existing condition exclusions for children under age 19
prohibited
• Adult children can remain on parents’ health insurance policy until
age 26
• Rescissions prohibited
• Cost-sharing on preventive care eliminated
• Selection of any available participating PCP; direct access to OB/Gyn
care
• New rules for internal appeals and external review
Check for any exclusions and exceptions
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7. What happens in 2014
• Generally, insurers must issue and continue in force to the
consumer any plan purchased (guaranteed renewability)
• Insurers may require the person to enroll during the initial open
enrollment period set by the Health Insurance Marketplace or upon a
special enrollment period
• Pre-existing condition exclusions/denials prohibited
• Annual dollar limits on EHB eliminated for most plans
• Underwriting in individual and small group markets only by:
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Age (3:1)
Tobacco Use (Up to 1.5:1)
Family Size
Geography (12 rating areas within Virginia)
Check for any exclusions and exceptions
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8. Essential Health Benefits (EHBs)
• Virginia EHB Benchmark plan:
• Anthem PPO KeyCare 30
• Plan with largest enrollment within product with largest enrollment
• Medicaid CHIP (SMILES) plan – pediatric dental
• Federal Employee Plan (FEP) Blue Vision plan for pediatric vision (default
plan)
• For further details on EHB requirements, visit:
• www.scc.virginia.gov/boi/co/acafilinginfo/index.aspx
Check for any exclusions and exceptions
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9. Essential Health Benefits (EHBs)
• In 2014, all new individual and small employer plans must
cover EHBs, which must include at least these 10 categories:
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Ambulatory Patient Services
Emergency Services
Hospitalization
Maternity and Newborn Care
Mental Health and Substance Use Service
Prescription Drugs
Rehabilitative and Habilitative Services & Devices
Laboratory Services
Preventive & Wellness Services & Chronic Disease Management
Pediatric Services (Oral* & Vision Care)
• Prior to 2014, limits prohibited or restricted on categories as
previously described
Check for any exclusions and exceptions
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10. Differences from the Benchmark
Policy
• 2014 market requirements
• New preventive services for adults, women and children
• Insurer may use different clinical review guidelines or
medically necessary criteria
• Routine adult vision benefits may be offered, but are not
required
• Medicaid CHIP (SMILES) plan covers cosmetic orthodontia, but
not required for EHB
Check for any exclusions and exceptions
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11. Minimum Required Services/Visits
(EHB)
• Skilled nursing facility
• 100 days per stay
• Mental Health/Substance Use
• no stated limit
• Habilitative/Rehabilitative Services
• 30 visits per calendar year combined for occupational/physical
therapy;
• 30 visits combined for speech therapy
Check for any exclusions and exceptions
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12. Minimum Required Services/Visits
(EHB) (cont’d)
• Private duty nursing
• actuarial equivalent of $500 per calendar year or 16 hours per
calendar year
• Home health care services
• 100 visits per calendar year
• Chiropractic care/spinal manipulations
• 30 visits per calendar year
Check for any exclusions and exceptions
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13. Minimum Required Services/Visits
(EHB) (cont’d)
• Pediatric oral and vision
• Routine dental exam twice/year
• One routine eye exam per year
• One pair standard glasses or lenses per year
• Early Intervention Services (birth – age 3)
• $5,000 limit no longer applicable
• Coverage for Prescription Drugs must include coverage of
same number of drugs in each category and class as
benchmark or 1, whichever is greater
Check for any exclusions and exceptions
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14. Effect of EHB on Virginia’s
Mandated Offers
• Section 38.2-3414 Obstetrical services mandated offer
• Included in benchmark
• Section 38.2-3418.15 Prosthetics mandated offer
• Included in benchmark
• Section 38.2-3418.3 Coverage for treatment of morbid
obesity
• Not included in benchmark
• Must still be offered with each plan
Check for any exclusions and exceptions
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15. Out-of-Pocket Costs
• There are limitations to the amount of total out-of-pocket expenses
consumers must incur for EHBs
• There are small group deductible limits for EHBs
• All new individual and small group plans must fall into one of the
following categories of cost-sharing (deductibles, copays,
coinsurance):
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Bronze: covers 60% of costs
Silver: covers 70% of costs
Gold: covers 80% of costs
Platinum: covers 90% of costs
Check for any exclusions and exceptions
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16. Levels of Coverage
Metal Level
(AV Level)
Bronze
Silver*
Gold*
Platinum
Premium Cost
Lowest
Moderate
Higher
Highest
Expected
Insurer Cost
60%
70%
80%
90%
Expected
Consumer
Cost
40%
30%
20%
10%
Check for any exclusions and exceptions
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17. Small Employers
• Small Employers are not required to offer health insurance,
but if they do they must offer coverage to all full-time
employees
• In Virginia, the small employer upper limit will remain at 50
employees 2014 and 2015. In 2016, the definition of a small
employer will be up to 100 employees
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18. Plan Management Review,
Monitoring and Oversight Duties
Bureau of Insurance
Department of Health
Licensed and in Good Standing
Accreditation Requirements and
Timeline
Plans and Benefits (variations for cost- Network Adequacy
sharing reductions)
Essential Health Benefits
Essential Community Providers
Actuarial Value Standards
Service Area
Rates (new and increases)
Program Attestations
Meaningful Difference
Marketing
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19. Qualified Health Plan Certification
• On July 31, the Bureau of Insurance recommended to the
Health Insurance Marketplace for certification in Virginia,
plans offered by:
• 9 individual carriers and 6 small employer carriers
• The Bureau also recommended for Exchange Certification
Stand-Alone Dental Plans (SADPs)
• 8 in the Individual and 13 in the Small Group Market (some for
inside and outside the Health Insurance Marketplace; some for
outside the Health Insurance Marketplace only)
For more information:
• http://www.scc.virginia.gov/boi/SERFFInquiry/default.
aspx
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20. Enrollment Periods
Inside and Outside the Marketplace
• Initial Open Enrollment Period:
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October 1, 2013 – March 31, 2014
November 15 – December 15, 2013 (Small employers not
meeting minimum participation and/or contribution
requirements)
• Subsequent Annual Open Enrollment Periods:
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October 15 – December 7
November 15 – December 15 (small employer)
• Special Enrollment Periods available throughout the year (3060 days)
• Small Employer/Employee Enrollment anytime during the year
if requirements met
• Employer may have 90-day waiting period on eligibility for
employee enrollment
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21. Remember This
• It is not required that you purchase coverage from the Health
Insurance Marketplace
• Coverage will be available outside the Health Insurance
Marketplace
• No law requires small employers to provide coverage
• No law requires employer-based coverage to end
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22. Assistance is Available
• The Bureau of Insurance staff can:
• Respond to insurance-related questions
• Investigate your complaints regarding your insurance coverage
• Provide tips to help you appeal a claim denial by your insurance
company
• Provide information on health care and alternative coverage
options
• Make appropriate referrals for issues outside our purview
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23. Other consumer support
• Agents can sell in the Health Insurance Marketplace in Virginia
if they are licensed and certified
• Agents may sell in the SHOP, but do not need to be certified by
the federal government
• Navigators receiving grants from each Marketplace will be
available to educate consumers about coverage offered
through the Health Insurance Marketplace and how to enroll;
special requirement to provide information in a culturally and
linguistically appropriate manner and accessible to people
with disabilities
• Other assistance personnel trained to educate consumers and
explain the enrollment process
• Health Insurance Marketplace and SHOP Call Centers
• Website: www.HealthCare.gov
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24. National Marketplace Toll-Free Call
Center
• A national call center will be used for all states with a Federally
Facilitated or Partnership Marketplace
• 1-800-318-2596 (TTY 1-855-889-4325)
• Open 24/7
• English and Spanish with Language Line for other languages
• SHOP call center for Employers:
• 1-800-706-7893 (TTY users: 1-800-706-7915)
• Monday through Friday, 9 a.m. to 5 p.m. EST
• Also available to Agents and Brokers
Questions related to operation of the Health Insurance
Marketplace or SHOP
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25. Helpful websites
Bureau of Insurance
http://www.scc.virginia.gov
Healthcare.gov
www.healthcare.gov
Training materials
http://marketplace.cms.gov
U.S. Department of Labor/EBSA
http://www.dol.gov/ebsa/healthreform
IRS ACA Tax Provisions Homepage
http://www.irs.gov/uac/Affordable-CareAct-Tax-Provisions-Home
U.S. Small Business Administration
www.sba.gov
FAQs on ACA
www.regtap.info
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26. Knowledge is Your Best Policy
State Corporation Commission
Bureau of Insurance
Life & Health Division
Mailing address:
P.O. Box 1157
Richmond, VA 23218
Street address:
1300 E. Main Street
Richmond, VA 23219
(877) 310-6560
Fax: (804) 371-9944
TDD/Voice (804) 371-9206
bureauofinsurance@scc.virginia.gov
www.scc.virginia.gov/boi
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