ACA Implementation:

Increase access to Health Insurance, Prescription Drug Coverage, Doctors and Hospitals

Completed in 2010

  • Established 12 year bio similar exclusivity
  • Expanded 340B drug discount program eligibility
  • Launched health plan web portal
  • Implemented insurance market coverage changes (no rescission, no lifetime maximums,  no pre‐existing condition exclusions for children, standard internal & external appeals processes)
  • Implemented MOE for Medicaid and CHIP
  • Established & funded HI tax credits for small employers
  • Established, funded the temporary early retiree reinsurance program
  • Instituted annual premium rate review requirement rules for states
  • Established mechanisms for requirements that private plans cover with no co‐pays preventive health services rated A or B


Completed in 2011

  • Started 10% Medicare payment bonus for primary care docs and general surgeons in professional shortage areas
  • Established employer disclosure requirements for value of health benefits on W‐2s
  • Established plan appeals process for coverage and claims determinations
  • Established, funded incentives for prevention of chronic diseases in Medicaid
  • Developed Medicaid Community First Choice Option and Medicaid home health programs for states
  • Implemented Medicare Part D Coverage Gap discount program
  • Established limited Medicare Advantage cost‐sharing requirements for FFS levels
  • Implemented MLR plan compliance requirements
  • Established, funded Medicare coverage of annual wellness visit with on cost‐sharing; prohibited cost‐sharing  on Medicare preventive services
  • Provided preliminary guidance on state operation of health insurance exchanges benchmarking coverage at “silver levels”

ACA Implementation:  Mechanisms

Completed in 2010

  • Instituted health insurance tax to fund PCORI

Completed in 2011

  • Imposed Annual fees on brand‐name pharmaceutical manufacturers and importers
  • Provided Health Insurance Exchange Planning Grants


ACA Implementation: New Jersey

Completed 2010

Established High Risk Pool‐ “NJ Protect”

Completed 2011

$1M Rate Review

$1M Exchange planning grant

2012 so far…

$7.6 M Exchange Level One grant

Legislation to establish a health insurance vetoed by Governor Christie


ACA Implementation:  New York

Completed 2010

Established High Risk Pool

$27.5 M Early Innovator Grant

$1.7M Consumer Assistance Program Grant

$1M Rate Review

Completed 2011

$4.4 M Rate Review (over 3 years)

$1M Exchange planning grant

2012 so far…

$59 M Exchange Level One grants; Level Two application due by June 30th (CSC awarded “system integrator” contract for Exchange)


Are we there yet?? Well…. not quite


2012 Implementation


  • Summary of Benefits & Coverage: requires group plans, employers and insurers to provide a uniform summary of benefits and coverage explanation prior to enrollment or re-enrollment by 3/23/12
  • Final Rule on Health Insurance Exchanges released (more on that later) (Can’t forget the arguments on ACA before Supreme Court including individual mandate constitutionality; sever-ability clause; and whether Medicaid expansion is “unconstitutionally coercive”)


  • ACOs become operational under the Shared Savings Program; all ACOs that start in 2012 will have agreement periods ending at the end of 2015
  • PCORI released its first report on research priorities for comparative effectiveness; 50 projects funded to the tune of $30 million


“The Nine” weigh in


  • Medicaid payments prohibited for provider‐preventable conditions; initially effective 7/1/11; delayed enforcement until 7/1/12


  • MLR Rebates Issued by 8/1


  • Medicare to start tying payments for inpatient hospitals to performance on quality measures for hospital discharges post 10/1
  • Medicare reduces payments for hospital readmission


Health Insurance Exchange:  FINAL RULE


Establishment & operation of a HIX by the states

  • HIX must receive HHS approval by 1/1/13 to offer QHPs by 1/1/14
  • States must submit an Exchange Blueprint to HHS detailing how the HIX meets statutory standards.
  • HHS can provide conditional approval to states if they show that they are likely to be ready by 1/1/14; states not ready for 2014 can apply for HIXs in 2015 and beyond


Participation requirements for health insurance companies in the HIX

  • HIXs may work with health insurers to structure QHP choices
  • HIXs have flexibility to set the timeline for health insurers to become accredited for their quality performance and changes to the grace period policy for QHPs
  • Mandates that the same premium rate must be offered regardless of whether the plan is offered in/out of the Exchange, or directly through issuer or through agent/broker. The preamble indicates that this requirement means that if the health plans are substantially the same as a QHP they should charge the same premium.


QHP Enrollment

Agents & Brokers

Agents and brokers may help individuals apply for advance payments of the premium tax credit and cost‐sharing reductions for QHPs.

Rule also permits agents and brokers to facilitate QHP selection through non‐Exchange website.



  • HIXs to award “Navigator” grants for duties to include:
    • maintaining expertise in enrollment, eligibility and program specifications
    • conducting public training and education activities to raise awareness of QHPs.
  • States must establish licensing or certification requirements
  • Navigators will not receive federal funding


Income SelfAttestation

  • HIXs may accept an applicant’s attestation of his/her projected annual household income for certain circumstances during the income verification process
  • HIXs will never accept such attestation without attempting to acquire tax data for purposes of verification of income for determining eligibility for advance payments of the premium tax credit and cost‐sharing reductions

Privacy & Security

  • Final rule includes additional standards for privacy and security of personally identifiable information, requiring HIXs to align such standards with those identified in the Office of the National Coordinator for Health Information Technology National Privacy and Security Framework for Electronic exchange of individually identifiable health information



  • HIXs will operate a SHOP for small businesses
  • States can establish the small group market as 1‐50 or 1‐100 employees until 2016.
    • In 2016, employer with 1‐100 employees can participate in a SHOP;
    • In 2017 employers with 100+ employees can participate
  • Requires SHOPs to develop and offer a premium calculator.
  • Starting in 2014, small employers (<25 employees) purchasing coverage through SHOP may be eligible for a tax credit up to 50% of their premium payments if they pay an average annual wage of $50,000 or less to employees, provide all FT employees coverage and pay at least 50% of the premium


Rate Reviews

  • HIXs are required to justify QHP rate increases on website.
  • Multi‐state plans are exempt from the HIX process for receiving and considering rate increase justifications.
  • Multi‐state plans are also exempt from the HIX process for receiving annual rate and benefit information.


Provider Networks & Integrated Care

  • QHPs must have an appropriate number of essential community providers, including mental and behavioral health specialists, geographically located, to provide care for low‐ income and medically underserved individuals.
  • Rule establishes an alternate standard for integrated delivery systems and staff model plans.


Health Insurance Exchange:  “INTERIM FINAL

HHS just closed comment period on several regulations published as “interim final” including:

  • Regulations related to the eligibility and enrollment requirement
  • Ability of states to allow agents and brokers to assist individuals in enrolling in QHPs, Medicaid and CHIP


Health Insurance Exchange: More guidance expected… on

  • Details about the HIX certification process and its timeline
  • Federally facilitated exchange
  • Exemptions for eligibility
  • Appeals of Individual Eligibility Determinations
  • QHP Quality Requirements
  • Individual Exemption Appeals


Lots of Reading & Learning …

  • At the very minimum, the study found a single coverage bronze plan with 20 percent co‐insurance and an out‐of‐ pocket cost‐sharing limit of 6350.00 would have a deductible of 4375.00 – and with 40% co insurance, the deductible would drop to $3475.00
  • A major health care market problem for NY is its high cost health care system, which is dominated by large hospital systems and academic medical centers in NYC and “must have hospitals in upstate markets. Because of hospitals’ market power, exchange premiums and federal subsidies are likely to be high. Another issue for NY relates to plans that currently dominate the public insurance market in NYC and whether they will participate in the Exchange.

 The Morning after the Supreme Court Weighs In

  1. The mandate alone is struck; insurance reforms remain.
  2. The entire law (or most of it) falls.
  3. The entire law stands.
  4. The mandate is struck along with insurance reforms.