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By Sara Hansard
April 10 --Health plans are likely to be more standardized on state-run Affordable Care Act marketplaces in 2015 to make it simpler for consumers to make choices, but marketplace directors are grappling with the issue of how to ensure adequate provider networks while encouraging competition and innovation in delivery models.
That was the assessment by directors of successful state-based marketplaces for California, New York, Washington, Connecticut and Kentucky on a press call April 10 sponsored by health-care consumer group Families USA. The first ACA open enrollment period for 2014 was between Oct. 1, 2013, and March 31, with a limited “special enrollment” period continuing through April 15 for people who tried to enroll through March 31 but weren't able to.
New York State of Health standardized benefits for each “metal” tier of actuarial coverage to help consumers make apples-to-apples comparisons of benefits, Executive Director Donna Frescatore said.
“As we go forward we see that as an area where we can even make that comparison process a little easier by making certain that any differences in health plans offered on the marketplace are meaningful, that they're just not nuances of difference where perhaps copayments or cost sharing has been changed just a little bit,” Frescatore said.
In addition, the New York marketplace wants to standardize the way plans are named, so that consumers can easily see which plans might include coverage, such as adult dental care, Frescatore said.
New York State of Health enrolled about 926,000 New Yorkers, including people who enrolled in marketplace qualified health plans (QHPs), the state's Medicaid program that was expanded under the ACA and children enrolled in its Child Health Plus program, Frescatore said. About 80 percent of the people who enrolled through the marketplace didn't have insurance, she said.
Covered California, which is likely to enroll more than 1.3 million state residents in QHPs once people who complete enrollment after March 31 are finished, and another 1.1 million people in Medicaid, is moving to “making sure people get care,” Executive Director Peter Lee said.
“We are looking very closely at all of our networks to make sure that consumers that enroll in the plans that we contract with have timely access to doctors and hospitals,” Lee said.
“The issue, though, of having right-size networks is having competition at the provider level,” Lee said. “Some plans contract with some sets of providers and others with others, whether that's hospitals or doctors. And the key part there, from our perspective, is educating consumers about the implications of their choice.”
Kevin Counihan, chief executive officer of Access Health CT, said health plans in the Connecticut marketplace are encouraged to experiment with new delivery models, such as patient-centered medical homes, accountable care organizations or tiered networks. Several carriers are introducing more value-based network options in 2015, he said.
The issue of provider networks “remains very dynamic,” Counihan said. A challenge for Access Health CT has been getting information about whether physicians in a network take new patients, he said. “That's something that we're working closely with the carriers to do better with,” he said.
Access Health CT enrolled nearly 199,000 people, exceeding its goal of 100,000, Counihan said. Nearly 79,000 have paid for QHPs and about 120,000 people enrolled in the expanded Medicaid program. The state expects to enroll more than 200,000 people in total by the time late enrollments are finished, he said.
“Network adequacy is always a delicate balance between open networks and cost and efficiency kinds of issues,” Washington Health Benefit Exchange Chief Executive Officer Richard Onizuka said.
Paid QHP enrollment in Washington was more than 146,000, and more than 268,000 people enrolled in the expanded Medicaid program, Onizuka said.
At a hearing held by the Senate Finance Committee April 10, Department of Health and Human Services Secretary Kathleen Sebelius said that 400,000 people have enrolled in private health plans through the marketplaces in addition to the 7.1 million enrollees announced April 1 by President Barack Obama, bringing the total number to about 7.5 million (see related story). Sebelius said the number is expected to continue to grow.
For 2014 marketplaces concentrated on getting people enrolled in the individual market, the directors said. An open question is how the ACA's Small Business Health Options Program (SHOP) for small group plans will fare in 2015, they indicated.
“I think SHOP is an experiment,” Counihan said. “I think it's going to take a few years to figure out if it works or not,” he said.
Employers who want to control their expense allocation for health plans and want to promote consumer-driven plans are enthusiastic about buying plans on marketplaces, Counihan said. “But it's a minority of the market,” he said. “It's a passionate minority, but it remains the minority,” he said. The Connecticut SHOP marketplace only has 39 accounts with an average size of 3.3 subscribers, he said.
The smallest companies are “beginning to divert some of their folks to either public or private exchanges,” Counihan said. The small group market didn't have the same type of “dysfunctionality” that the individual market did, and the need for a small group market is more segmented, he said.
All of the marketplace directors speaking on the Families USA call said they want the HHS to issue regulations early for 2015 enrollment, which begins in November. “The more stability that we can get out of the rules and so forth from HHS the better off everybody's going to be,” Bill Nold, deputy executive director of the Office of the Kentucky Health Benefit Exchange, said. Nold said he expects the federal regulatory process to improve next year.
Kentucky has enrolled about 400,000 people, Nold said. About 315,000 are in the state's Medicaid program, with the balance in QHPs, he said.
More than 44 percent of the QHP enrollment in the state was through an insurance agent, he said. “We wanted early on to make sure that our insurance agent community was very much involved in the process, and it appears they have been engaged,” he said. “As time goes on as we get into the next enrollment period, we'll have even more interest from our agent community in helping people get enrolled.”
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