HEALTH IN COLORADO

GOVERNOR HICKENLOOPER’S VISION

Coverage & affordability framework Insurance market reforms Individual mandate Affordability protections

Insurance reforms Insurance market reforms Dependent care coverage for adult children to age 26 No pre-existing conditions exclusions for children No lifetime limits No rescissions Medical Loss Ratio to 80% ind. market and 85% large group market (2010 reporting, 2011 rebates) Free preventive care (new plans) Begin phase out of annual limits No annual limits Guaranteed issue Guaranteed renewability No gender rating No health status rating Age rating 3:1; Geographic variation/tobacco rating 1.5:1

Individual mandate All citizens and legal residents required to have coverage starting 2014 Exceptions: religious objection; Native Americans; financial hardship; lowest cost plan > 8% of income; undocumented immigrants; gaps of 3 months or less Penalties assessed through federal income tax for each uninsured family member to be phased in starting in 2014 at $95/individual or 1 percent of household income. In 2016 penalty = $695/adult, $375/child or 2.5% of income. Maximum of $2,085 per family or 2.5% of income, whichever is greater.

Affordability Provisions Medicaid expansions: all non-disabled under age 65 eligible up to 133% of poverty Premium tax credits available up to 400% of poverty Cost sharing subsidies up to 250% of poverty (limits out of pocket spending) New marketplace for accessing coverage Affordability protections

Coverage access points Uninsured health reform coverage access points Medicaid Medicare Employer based coverage Health insurance exchanges and nongroup

>$89,400 for a family of four; >400% of FPL  Job-based coverage, or  Full-cost coverage in the exchange $67,050-$89,400; % of FPL  Job-based coverage, or  Subsidized exchange coverage: premiums capped at 9.5% of income $55,875-$67,050; % of FPL  Job-based coverage, or  Premium tax credit to cap premiums at 6.3 – 9.5% of income $29,725-$55,875; % of FPL  CHP+ (Children and pregnant women)  Job-based coverage, or  Premium tax credit to cap premiums at 3% - 6.3% of income, and out of pocket subsidy <$29,725 for a family of four; < 133% FPL  Medicaid  Premium tax credit to cap premiums at 2% of income, and out of pocket subsidy Family Income Coverage Options by Income (2014) Family income based on 2011 federal poverty guidelines for a family of four; Source: Center for Public Policy Priorities, cppp.org

Medicaid Medicaid will be expanded to 133% of federal poverty in Income eligibility based on modified adjusted gross income + 5% income disregard for nondisabled persons <65. Option for states to allow patients with chronic conditions to designate a health home (mental health included) and get increased federal match. The federal government will provide states 100% funding for expansion through 2016 with a gradual reduction to 90% in Medicaid primary care payment rates will increase to 100% of Medicare rates in 2013 and State must maintain coverage levels until 2014 for adults, 2019 for children and until 2019 for CHP+.

Employer Coverage Small employers (<50) are not required to provide employee coverage. Have access to an Exchange. Tax credits available for small businesses (up to 25 employees with average wages under $50,000, if 50% of premium paid) to provide employer coverage starting – Up to 35% now, 50% Large employers (>50) pay a penalty per full-time employee if an employee receives subsidized coverage in the exchange. Employees who have an offer of employer coverage generally cannot purchase in the exchange, with a few exceptions.

Medicare Eliminate the “donut hole” by 2020 starting with $250 rebate in 2010, 50% discount on name brand drugs in Expands number of covered preventive services and eliminates cost sharing starting % bonus payment for primary care physicians and general surgeons in health care shortage areas ( ). Improved care coordination and integration for dual Medicare/Medicaid eligible enrollees. Restructure Medicare Advantage payments Require 85% medical loss ratio for Medicare Advantage Extend Medicare solvency by 12 years to 2029.

Implementation in Colorado

SB11-200: CO HEALTH BENEFIT EXCHANGE ACT OF 2011

Colorado Health Benefit Exchange Activities

COST CONTAINMENT

Statewide Data and Analytics Contractor (SDAC) Primary Care Medical Providers (PCMPs) Regional Care Collaborative Organizations (RCCOs)

QUESTIONS & ANSWERS George Lyford Health Care Attorney Colorado Center on Law and Policy , ext. 310 Lorez Meinhold Senior Policy Director Governor John Hickenlooper colorado.gov/healthreform