So What's Really Going to Happen to the Group Market

[HealthGuy]

How many people again were projected to sign up for the federal high risk pool, and how many people actually did? The federal high risk pool has been a complete failure. As is will be any state or federal health exchange not allowing fair compensation to an agent assisting with enrollment. Any way you slice it, the exchanges are going to be a complete failure without agents. Hell, Medicare is less confusing than these exchange subsidy rules, and look at the agents making a living selling Medicare. Again, I argue: EXCHANGES WILL COMPLETELY FAIL WITHOUT AGENTS. I don't believe there is going to be a massive influx into exchanges just because the federal gov't wills it so. Agents have to be a part of this. Prove me wrong...John, I know your argument is what exchange plan do you want: bronze, silver, or platinum...But I tell you people are too dumb to even understand anything about health insurance, not to mention subsidy reimbursement. Failure is on the horizon without us in some manner or regard.

 

[Yagents]

Kathleen feels employer group will grow:

[FONT=Arial, Helvetica, sans-serif]Modern Healthcare: Sebelius Sees Exchanges Bolstering Employer Coverage
A year and a half before HHS plans to begin enrolling people in state and federal health insurance exchanges, it remains unclear how many employers will drop their employee coverage due to that option, said HHS Secretary Kathleen Sebelius. In testimony before the Senate Finance Committee Wednesday on the administration's fiscal 2013 budget proposal, Sebelius said she expects the coming insurance marketplaces to bolster employer-sponsored coverage by allowing those companies to buy coverage there (Daly, 2/15).[/FONT]

 

[Crabcake Johnny]

Healthguy: You may be forgetting on important fact; come 2014 when implementation occurs, the only place anyone will be allowed to buy an individual plan will be through their exchange. If they do not, and choose excempted coverage outside of the exchange, it will not "count" and they'll be fined.

Similar to the Mass. Connector, if you want to buy an individual plan, the only way you can do is is through the state Connector.

 

[ABC]

Listen, any batshit crazy author can write an article. Nothing in the law blocks people from receiving a subsidy if they choose a federally administered exchange. It's only about how they receive the subsidy.

Same with the WSJ article. When asked, the government said "we don't see it being an issue." Well, the author thought it was still an issue. Fine, that's his right. There won't be an issue regarding this come implementation in 2014. But anyone can chose to wear the tin foil hat if they want to.

True dat, but you have to admit this could turn into another legal battle. Anyone can view the law as they see fit but it could come down to how the judge views the law.

 

[Yagents]

Healthguy: You may be forgetting on important fact; come 2014 when implementation occurs, the only place anyone will be allowed to buy an individual plan will be through their exchange. If they do not, and choose excempted coverage outside of the exchange, it will not "count" and they'll be fined.

Similar to the Mass. Connector, if you want to buy an individual plan, the only way you can do is is through the state Connector.

This is incorrect. Most states will have private exchanges, it's written in the law to allow them. MD may not, nor VT or NY, but most level headed states will provide an alternative.

 

[Crabcake Johnny]

By 2014 every state must establish an exchange. If they don't then the government will administer the exchange.

But it stands that the only way someone will be able to buy an individual policy is either through their state's exchange or their state's government administered exchange.

All policies sold outside of the exchange do not count as compliant coverage for avoiding a fine. And states can absolutely have a private exchange. Doesn't matter. You still won't be able to buy a plan outside of any exchange and have it "count."

Vermont, for example, has filed to run their own private exchange. Fine, but that will be the only way anyone in Vermont will be able to obtain an individual policy.

 

[Dave020]

By 2014 every state must establish an exchange. If they don't then the government will administer the exchange.

But it stands that the only way someone will be able to buy an individual policy is either through their state's exchange or their state's government administered exchange.

All policies sold outside of the exchange do not count as compliant coverage for avoiding a fine. And states can absolutely have a private exchange. Doesn't matter. You still won't be able to buy a plan outside of any exchange and have it "count."

Vermont, for example, has filed to run their own private exchange. Fine, but that will be the only way anyone in Vermont will be able to obtain an individual policy.

???????????? In California, carriers will be allowed to sell all four precious metals plans in AND out of the exchange. Gold outside of the exchange "counts" the same as Gold inside of the exchange. They can also sell the Cat plan outside so long as they sell it inside. No other NGF plans will be allowed outside of the CA individual exchange.

Outside will pay full commission. Inside, we don't know and likely in CA agents will be barred from selling inside if they choose to sell outside to avoid perceived adverse selection.

There will also be a SHOP exchange for small group which may pay a commission (likely PMPM flat) to agents.

 

[Crabcake Johnny]

Dave - I'm only going by the language contained in the actual bill that was passed into law. It states that coverage purchased outside of the exchange is called "exempted" coverage which does not quality for a subsidy and does not count towards satisfying coverage to avoid a fine.

It this all a huge clusterf**k? You betcha.

 

[Ann H]

Unlike Massachussettes, the PPACA states that anyone purchasing qualifying coverage outside the exchange is not subject to the IRS penalty. "Qualifying" coverage means it must be at least essential benefits, and have the same pricing as plans inside the exchange.

The law is very, very confusing, and as you can see even agents like us have to revisit the law to remind ourselves about the confusing issues. I certainly appreciate it when one of you guides me in the correct direction and/or corrects my mistakes. I hope nobody takes offense at the "back and forth" over issues in the law, and correction of misinformation.

The Kaiser calculator is handy. But it's very incomplete. For instance, it doesn't help you calculate the subsidy for a married couple, or a single person with 2 kids, or a family of 3. Also, it doesn't take into account the subsidies that people may receive for cost sharing. Many who get a premium subsidy will also receive "cost sharing" subsidies meaning that the govt will help them pay for their copays & deductibles.

So, in looking at your book of business, divide it into 3 sections - those that clearly will go to the exchange, those that are in the middle, and those whose income is clearly above 400% of FPL and probably won't go to the exchange. Now, on those that are in the middle, you should do some calculating to predict if you could lose that client to the exchange or not.

To help you make that quick "3 section" division of your book of business, start with this:

• Estimate if the Individual or Family is below 400% of FPL. You can use this table Federal Poverty Guidelines
• Use the Kaiser calculator at Health Reform Subsidy Calculator - Kaiser Health Reform to estimate if the expected cost of insurance is less than 9.5% of the person's income. If so, he/she does not qualify for a premium subsidy even if his income is below 400% of FPL. If you live in a state with low premiums, the "regional cost factor" field in the Kaiser calculator should be "low", and if you live in Alaska, CA or one of the GI states it should be "high", but for most states just use "medium".
• Look over the flow chart I give a link to below, and see if there's another reason your client won't qualify for a subsidy, like if their spouse has affordable coverage at work, or if the client is under age 26 and can get on a parent's plan...

This should help you divide your book of clients into 3 sections.
Now, if you want to get really technical about whether a client would qualify or not, there's a fantastic flow chart found at http://www.chrt.org/assets/aca-flowchart/CHRT-ACA-Flowchart-2011-12-Tabloid.pdf that shows the bzillion different issues at play over who qualifies and who doesn't. There's another really great calculator by the Wall Street Journal at What does the health care bill mean to me? (washingtonpost.com). Also, the Kaiser calculator has a link to tables that are relevant, and I can't seem to paste the link, so just fill out the Kaiser calculator table, and at the bottom will appear links, and one of them reads "click here for tables showing results by income and age".

 

[stuy119]

Remember, any "loopholes" that are to be closed will need to be done by Congress. Right now, the House is under Republican control and won't agree to anything that will further PPACA. Assuming that the Dems don't post gains in the House (and can possibly lose the Senate), there will be no fixes for any issues in the bill - and there will be less funding for PPACA in its current state. Of course, all of that assumes it keeps its form after the USSC decision.

There are still too many variables to know how this will play out. I would plan for the worst but hope for the best.