What patient advocacy organizations need to know as they help people with chronic conditions understand the essential health benefits provided under the Affordable Care Act and assist people in enrolling in state exchanges

1. Preparing Your Staff and Patients
for Exchange Enrollment
July 17, 2013

2. Essential Health Benefits:
We’ve Only Just Begun
Marc Boutin, JD
Executive Vice President and COO
National Health Council

3. The mission of the National Health Council is
to provide a united voice for people with
chronic diseases and disabilities.

5. © National Health Council
Putting Patients First®
 Cover Everyone
 Curb Costs Responsibly
 Abolish Exclusions for Pre-existing
Conditions
 Eliminate Lifetime Caps on Benefits
 Ensure Access to Long-tem and End-of-life
Care
GOAL: Engage individuals in a nationwide effort to create and implement
a modern health care system, based on 5 Principles for Putting Patients
First®

6. © National Health Council

7. © National Health Council
Essential Health Benefits
Broad Definition
of Covered Services
―
Specific List of
Exclusions

8. © National Health Council
Patient Protections
 Anti-Descrimination
 Medical Necessity
 Exceptions and Appeals
 Continuity of Care
 Prohibition of Specialty
Tiers
 Limited Cost Sharing
 Part D Protected Classes

9. © National Health Council
Patient Community Wins
 Drug Formulary must have
the same number of
prescription drugs in each
class as that of the EHB-
benchmark plan
 States must monitor and
identify discriminatory
benefit designs
 The ability of health plans
to substitute benefits is
limited.

10. © National Health Council
Tools:
 Choosing an appropriate plan
 Evaluation and Tracking Tool
Patient Advocacy Tools

11. © National Health Council
Public Policymaking Process in the U.S.
Interest Group Preferences, Demographics, Technological Inputs
Policy Modification Phase – Feedback
Policy
Formulation
Phase
Development of
Legislation
Policy
Implementation
Phase
Rulemaking Application
Based on Health Policymaking in the United States, 2nd Edition, by Beaufort B. Longest Jr.

12. State Exchanges
and Medicaid Expansion:
What do you need to know?
Kelly Brantley
Senior Manager
Avalere Health, LLC

13. © Avalere Health LLC
Page 13
Agenda
 Coverage Expansion
 Affordability in Exchanges
 Enrollment
 Federal and State Consumer Outreach and Enrollment Activity
» Opportunities for NHC Members to Participate
 Next Steps
 Q&A

14. Coverage Expansion
The intersection of business
strategy and public policy

15. © Avalere Health LLC
Page 15
The ACA Is Expected to Reduce Number of Uninsured,
Primarily through Enrollment in Medicaid and Exchanges
Source: Avalere Enrollment Model, June 2013. Assumes 26 states opt out of the Medicaid expansion. Avalere
assumes that: Arkansas enrolls new Medicaid eligibles into the exchange through premium support, Iowa enrolls
new Medicaid eligibles over 100 percent of poverty into the exchange through premium support, and Wisconsin
reduces Medicaid eligibility to 100% FPL and moves these individuals in the exchanges.
ACA = Affordable Care Act
49 40 35 26
54 59 61
62
8 12 22
16 13 12 11
141 140 141 141
5 5 5 5
50 52 53 55
2013 2014 2015 2016
Expected Sources of Coverage (in Millions), 2013-2016
Medicare
Other Public Programs
Employer
Non-Group
Exchanges
Medicaid and CHIP
Uninsured

16. © Avalere Health LLC
Page 16
Health Reform Broadens Medicaid Eligibility Substantially
 The ACA required states to expand the Medicaid program…
» Required states, beginning in 2014, to cover all individuals who are under
65, do not receive Medicare, and have income below 133% FPL
» Largely affects parents and childless adults who are not disabled
 …but the Supreme Court rendered the expansion optional
» The court ruled that states must be given a choice about whether or not to
move forward with the ACA’s Medicaid expansion
» The federal government cannot cut off existing Medicaid funding to states that
choose not to proceed with the expansion
ACA = Affordable Care Act
FPL = Federal Poverty Level
Expansion largely will help parents and childless adults who are not
disabled. Most states only cover parents at much lower income
levels, and very few states cover any childless adults unless they are
disabled.

17. © Avalere Health LLC
To Date, 23 States & DC Plan to Expand Medicaid Eligibility in
2014, 21 Will Not Expand, and the Remainder Are Undecided
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KS
COUT
TX
NM
SC
FL
GAALMS
LA
AR*
MO
IA*
VA
NC
TN*
IN
KY
IL
MI
WI
PA
NY
WV
VT
ME
RICT
DE
MD
NJ
MA
NH
WA
OH
DC
Will Expand (23 + DC)
State Commitment to Expand Medicaid Eligibility in 2014
Leaning No (6)
Will Not Expand (21)
Source: Avalere State Reform Insights, Updated July 15, 2013
* Considering a premium assistance model for expansion using exchange plans for some or all beneficiaries

18. © Avalere Health LLC
Page 18
Exchanges Aim to Offer One-Stop Shopping to Individuals and
Small Businesses, Similar to Online Travel Sites
Exchange Governing Body
Individual Exchange
SHOP Exchange
26 M enrollees
Majority are subsidized
individuals; No subsidies
for those with ESI*
Unknown number of
groups with ≤100
workers
* Individuals with an offer of employer-sponsored insurance (ESI) are not eligible for subsidies unless their
individual employer premium exceeds 9.8% of their income or does not provide minimum value.
Source: Avalere Health Enrollment Model, June 28, 2013.

19. © Avalere Health LLC
Page 19
By 2019, About 26 Million People Will Gain Health Insurance
Coverage through the Exchanges
Projected Number of Exchange Enrollees, 2014-2019
Enrollment(Millions)
7
10
19
21 21 21
1
2
4
4 4 5
0
5
10
15
20
25
2014 2015 2016 2017 2018 2019
Subsidized Unsubsidized
Source: Avalere Enrollment Model, June 2013. Assumes 26 states opt out of the Medicaid expansion. Avalere
assumes that: Arkansas enrolls new Medicaid eligibles into the exchange through premium support, Iowa enrolls
new Medicaid eligibles over 100 percent of poverty into the exchange through premium support, and Wisconsin
reduces Medicaid eligibility to 100% FPL and moves these individuals in the exchanges.

20. © Avalere Health LLC
Page 20
State-Run Exchange
State Partnership
Exchange (SPE)
Federally Facilitated
Exchange (FFE)*
States Have Three Options with Varying Degrees of State
Responsibility for Exchange Functions
 States have three options:
1) Perform plan
management only
2) Perform consumer
assistance only
3) Perform both plan
management and
consumer assistance
HHS will manage technical
functions – eligibility and
enrollment, financial
management, etc.
Partnership blueprints were
due on February 15, 2012
 States manage core
exchange functions:
» Plan management
» Consumer assistance
» Eligibility and enrollment
» Financial management
The ACA appropriates
state establishment grants
to support these activities
through 2014
Exchange blueprints were
due on November 16,
2012
ACA requires HHS to run a
FFE in any state that does
not set up an exchange
States with the FFE will not
control key exchange
functions, although the
federal government is
consulting with states on its
design
FFE states will retain
traditional responsibilities of
their insurance departments
HHS = Department of Health and Human Services
* HHS has approved eight FFE states—KS, ME, MT, NE, OH, SD, UT and VA—to operate the ―Marketplace Plan
Management‖ model in which these states will perform plan management.

21. © Avalere Health LLC
Page 21
16 States and DC Will Run Exchanges in 2014, While 6 States
Will Pursue Partnerships, and the Rest Will Rely on the FFE
Source: Avalere State Reform Insights, July 15, 2013.
*In addition to the marketplace plan management model for its individual exchange, Utah will rely on its existing small group
exchange as its SHOP.
**While New Mexico will operate a partnership for its individual exchange, the state will run its own SHOP.
*** Although Idaho will operate a state-based exchange, it will rely on HHS for certain functions, such as eligibility and
enrollment.
Insurance Exchange Operational Model
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID***
WY
OK
KS
CO
UT*
TX
NM**
SC
FL
GA
ALMS
LA
AR
MO
IA
VA
NC
TN
IN
KY
IL
MI
WI
PA
NY
WV
VT
ME
RICT
DE
MD
NJ
MA
NH
WA
OH
D.C.
FFE – Marketplace Plan
Management (8)
State-Run (15 + DC)
FFE (20)
Partnership (7)

22. Affordability in Exchanges
The intersection of business
strategy and public policy

23. © Avalere Health LLC
Page 23
Plans in the Individual and Small Group Market, Including
Exchange Plans, Must Offer the Essential Health Benefits
1. Essential Health Benefits
» Applies to all individual and small group plans
2. Out-of-Pocket Limits (OOP)
» Applies to all plans – OOP cap is tied to annual HSA limits ($6,350 for an individual in 2014)
3. Actuarial Value
» All individual and small group plans in the exchange must offer Silver and Gold
Ambulatory patient services Prescription drugs
Emergency services Rehabilitative and habilitative services and devices
Hospitalization Laboratory services
Maternity and newborn care Preventive and wellness services and chronic disease management
Mental health and substance abuse services Pediatric services (including oral and vision care)
Bronze Plan covers 60% of healthcare costs
Silver 70% of healthcare costs
Gold 80% of healthcare costs
Platinum 90% of healthcare costs
Actuarial Value = A measure of a benefit generosity that is expressed as percent of expenses paid by the insurer
HSA = Health Savings Account

24. © Avalere Health LLC
Page 24
Exchange Plans Will Follow Set Metal Levels & Will Be Less
Generous than Employer Coverage
Insurance Plan % of Patient Costs
Covered by Plan
Typical Employer Plan (HMO)1 93%
Platinum 90%
FEHBP Blue Cross Blue Shield
Standard Option (PPO) 1
87%
Typical Employer Plan (PPO)1 80.0% - 84%
Gold 80%
Medicare Parts A, B and D1 76%
Silver 70%
Bronze 60%
1. Peterson, Chris. ―Setting and Valuing Health Insurance Benefits.‖ Congressional Research Service. (2009)
Most enrollees are expected to select lower-premium Silver and Bronze plans, which will
include very high out-of-pocket requirements for patients.
May have very high cost-
sharing—enrollees could be
underinsured

25. © Avalere Health LLC
Page 25
Exchanges Will Offer Premium and Cost-Sharing Subsidies
Premium Subsidies: Sliding scale tax credits to limit premium spending as a percent of income for
individuals under 400% FPL; Applies to the second lowest cost Silver plan available in the exchange
Cost Sharing Reductions: Provides cost-sharing subsidies for individuals with incomes below 250% FPL
Income Premiums Limited to % of Income
<133% FPL 2.0%
133 – 150% FPL 3.0 - 4.0%
150 – 200% FPL 4.0 – 6.3%
200 – 250% FPL 6.3 – 8.05%
250 – 300% FPL 8.05 – 9.5%
300 – 400% FPL 9.5 %
FPL = Federal Poverty Level
OOP = Out-of-Pocket
Household
Income
Reduction in OOP Limit Actuarial Value
100 - 150% FPL 2/3 94%
150 – 200% FPL 2/3 87%
200 – 250% FPL 1/5 73%
250 – 400% FPL None, given AV level 70%

26. © Avalere Health LLC
Page 26
Initial Rate Filings Show Wide Variation in Silver Plan
Premiums within and among States
$222 $233
$300
$232
$197
$286
$201
$400
$264
$326
$370 $362
$314
$291 $310 $299
$432
$311
$476
$659
$441 $429
$549
$332
$436
$454
$359
$-
$100
$200
$300
$400
$500
$600
$700
CA (13) CO (10) CT (4) OH (5) OR (12) RI (2) VA (5) VT (2) WA (7)
MonthlyPremium
State (Number of Carriers)
Monthly Silver Plan Premiums for Nonsmoking 40-Year-Olds
for Exchange Plans*
Minimum Average Maximum
* Rates are for plans filed to be offered through exchanges for nonsmoking 40-year-old individual. Data are for the
minimum, maximum, and averages across all regions within a state.
Source: Avalere Health analysis of health insurance rate filings publicly available as of June 12, 2013.

27. © Avalere Health LLC
Page 27
Case Study: Despite Health Care Reform’s OOP Limit, Patients
with Rare Diseases Will Face High Initial Costs for Their Drugs
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
First Month's Rx Fill Second Month
Estimated Drug Spending for Rare Disease Patients in
Exchange Coverage
Assumes $15,000 Monthly Drug Cost
VT Deductible
CA Silver Coinsurance Plan
MA, NY Silver*
OR Standard Silver Plan
CT Standard Silver
Source: Avalere Health analysis based on states’ 2014 standardized benefit designs for silver-level plans in their
exchanges. Calculations are based on a prescription drug with a cost of $15,000 per month that is placed on a plan’s
highest-cost formulary tier. Assumes no other drug or medical spending by the patient during the year.
* MA and NY each have a standard silver plan design with the same overall deductible amount, tier 3 cost sharing, and
OOP maximum, although the benefit designs differ on cost sharing amounts for other services not included in this analysis.

28. © Avalere Health LLC
Page 28
The Affordable Care Act Introduces New Protections
Invaluable to Patients with Special Healthcare Needs
• Insurers must cover treatment for conditions patients had prior to
obtaining coverage
Pre-existing Condition Exclusions
• Insurers cannot turn down patients based on health status for initial
enrollment or renewals
Guarantee Issue
• Insurers may only vary the premium rates for enrollees on the basis
of four factors: family size, rating area, age, and tobacco use
Rating Rules
• Insurers must combine the claims experience across all enrollees in
each market when setting premiums
Single Risk Pool

29. Enrollment
The intersection of business
strategy and public policy

30. © Avalere Health LLC
Page 30
Options for Enrollment in Exchange Coverage Will Include an
Online Web Portal and In-Person Assistance
Medicaid /
CHIP
Apply for Coverage Select Benefit & Health Plan
Platinum
(90%)
Gold
(80%)
Silver
(70%)
Bronze
(60%)
United
Humana
CIGNA
Aetna
WellPoint
BC/BS
Regional
Complete
Enrollment
Income
Verification
Process
Exchange
without
Subsidy
Exchange
with
Subsidy

 Exchange portals will allow individuals to determine eligibility for exchanges and
subsidies
 Consumers will be allowed to select from three to four coverage levels* and from a
variety of benefit designs and carriers
 In-person assistance will be available to aid consumers in enrollment decisions
* Individuals receiving cost-sharing reductions must purchase silver-level coverage

31. © Avalere Health LLC
Page 31
Patients Can Enroll Beginning in October, with Coverage
Effective as Soon as January 1
July August Sept October Nov Dec Jan Feb March April
2013 2014
 For enrollments between October 1 and December 15, 2013, coverage will be effective January
1, 2014
 After December 15, for enrollments between the 1st and 15th day of the month, coverage will
begin the first day of the next month. For enrollments between the 16th and the last day of the
month, coverage begins the first day of the second following month.
 Patients will be able to enroll outside of the open enrollment period only if they experience
qualifying events including:
» Marriage or divorce
» Loss of other insurance coverage (from an employer, for example)
» Become eligible for subsidies due to change in income
October 1: Open
Enrollment Begins
January 1: New
Coverage Effective
March 31: Open
Enrollment Closes

32. © Avalere Health LLC
Page 32
The ACA Requires People Who Do Not Have Health
Insurance to Pay a Penalty, Which Phases Up in Later Years
Year Penalty
2014
Greater of $95 or 1% of income (offset by
filing threshold)
2015
Greater of $325 or 2% of income (offset
by filing threshold)
2016
Greater of $625 or 2.5% of income (offset
by filing threshold)
2017
Greater of $625 (+ cost of living
adjustment) or 2.5% of income (offset by
filing threshold)
Penalty amounts increase in future years, but are capped at bronze
premium levels
Source: IRS, Proposed Rule, Shared Responsibility Payment for Not Maintaining Minimum Essential Coverage, January
2013.

33. © National Health Council
State Navigators, Assisters, and
Counselors: How to work with them
Purva Rawal
Senior Manager
Avalere Health, LLC

34. Consumer Outreach and
Enrollment Activity
The intersection of business
strategy and public policy

35. © Avalere Health LLC
Page 35
HHS and States Focused on Consumer Outreach and
Enrollment As October 1 Approaches
 Exchanges must have fixed, annual open enrollment periods with special enrollment
periods for particular circumstances
» Initial open enrollment period will run from October 1, 2013 through March 31, 2014
» In subsequent years, annual enrollment will run from October 15 through December 7
of each year
 Major federal, state, and private marketing efforts are expected to begin this summer to
draw attention to the coverage expansions and the exchange marketplaces in time for
enrollment assistance on October 1, 2013
APR MAY JUN JUL AUG SEPT OCT NOV DEC JAN FEB MAR
October 1, 2013-March 31, 2014: Initial open
enrollment in the individual exchange
October 15-December 7:
Annual open enrollment in
the individual exchange

36. © Avalere Health LLC
Page 36
Patients Will Need Support across Three Domains
• Although many people will qualify for federal subsidies in the
exchanges, individuals may still have trouble affording
premiums
• Affordability may vary greatly by state depending on
enrollment trends and the payer landscape
Premiums
• Awareness of new coverage options is low and the process
for applying will be complex for many to navigate
• Patients will require non-bias, informed support from
navigators and non-navigator assisters in order to enroll in the
plan that best meets their needs
Enrollment
• Cost sharing for upper tiered medications is expected to be
high, ranging from 20-50% on tiers 3 and 4 in states with
standardized plan designs
• While some patients will be eligible for cost-sharing
subsidies, many will need support accessing medications
before they meet the OOP limit
Access to
Providers and
Treatments

37. © Avalere Health LLC
Page 37
HHS Has Proposed Three Separate Consumer Assister
Entities to Boost Exchange Enrollment
Navigator In-person Assisters
Certified Application
Counselor
Roles and
Responsibilities
Assist and educate
individuals to receive
eligibility determination
from exchange and
help with enrollment
Provide similar
assistance as Navigator
to supplement the
Navigator program for
the initial years of the
exchanges
Assist consumers in
completing and
gathering information
for single streamlined
eligibility application for
Medicaid, exchanges
Funding Grants from HHS in
FFE and SPEs, grants
from the state
exchange in SBEs
Exchange
Establishment Grants
Self-funded; federal and
exchange grants not
available
States FFE, SPE, SBE SPE, Optional SBE FFE, SPE, SBE
FFE = Federally Facilitated Exchange; SPE = State-Partnership Exchange; SBE = State Based Exchange
Source: Centers for Medicare & Medicaid Services. Proposed Rule on Standards for Navigators and Non-
Navigator Assistance Personnel. Released April 3, 2013.
The multiple consumer assister options, differing funding streams, and staggered
application deadlines –in the absence of final rules - are challenging to those trying
to identify what consumer assister roles they can play and where.

38. © Avalere Health LLC
Page 38
States with RFPs for Navigators, IPAs, or Certified Application Counselors
AK
HI
CA
AZ
NV
OR
MT
MN
NE
SD
ND
ID
WY
OK
KS
CO
UT
TX
NM
SC
FL
GA
ALMS
LA
AR
MO
IA
VA
NC
TN
IN
KY
IL
MI
WI
PA
NY
WV
VT
ME
RICT
DE
MD
NJ
MA
NH
WA
OH
D.C.
RFP Released (12 + DC)
No RFP (40)
To Date, 12 States and DC Have Issued RFPs for Consumer
Assistance Programs
Source: Avalere State Reform Insights, July 15, 2013.

39. © Avalere Health LLC
Page 39
States Are Spending on Consumer Assistance More Heavily
than HHS
$54
$16
$43
$17
$5
$10
$0.43
$28
$24
$4 $4
$13
FFE AK CA CO CT DC HI IL MD MN NV VT
Spending on Consumer Assistance Programs, in Millions
Avalere analysis based on publicly reported spending on consumer assistance programs, including navigators and IPAs.
Source: Avalere State Reform Insights, July 15. 2013

40. © Avalere Health LLC
Page 40
HHS Has Made Steady Progress on Consumer Assistance
Programs, But Significant Work Still Must Be Accomplished
Funding Delays Training Plan
A
Outstanding Activities
 The funding
announcement for the
Navigator program was
delayed until April 9, 2013
and CMS indicated only
one round of awards
would take place.
 The anticipated award
date is now August
15, 2013 and CMS
expects to make awards
to at least two different
applicants in each of the
34 FFE states and 33 FF-
SHOP states.
 Federally funded in-person
assisters, including
Navigators, must be
trained and certified before
conducting outreach
assistance activities.
 CMS plans to complete the
development of the
Navigator training
curriculum and certification
exam by August 2013 and
will begin training once the
curriculum is published.
 CMS recommended that in-
person outreach activities
begin in the summer of
2013 to educate small
employers and employees
in advance of the open
enrollment period.
 In addition, HHS is
targeting marketing and
outreach efforts to specific
populations, such as young
adults and Hispanics.
Source: GAO Report: Status of Federal and State Efforts to Establish Federally Facilitated Health Insurance Exchanges.
June 2013. Available at: http://www.gao.gov/assets/660/655291.pdf

41. © Avalere Health LLC
Page 41
Navigators and Assisters Must Be Trained Quickly and
Prepared to Reach Varied Populations
• Minorities expected to be disproportionately represented—need for
consumer assister services in other languages
• Population expected to have lower educational attainment compared
to those with ESI requiring materials at appropriate literacy levels, etc.
Population
• Navigators and non-Navigator assistance personnel must obtain
certification through the exchange, complete and pass an HHS-
approved training, and obtain continuing education and be recertified
• CMS estimates training will take up to 30 hours for certification
Training
• Navigators and non-Navigator assistance personnel must be trained
and certified quickly in anticipation of open enrollment October 1
• Interested entities must apply by June 7, with awards made by August
15 (letter of intent due May 1)
Timing
Patient groups and community-based organizations could play a critical role in
educating Navigators and IPAs on the benefit design features enrollees with special
needs or chronic health conditions should consider before selecting a plan.

42. © Avalere Health LLC
Page 42
Opportunities for NHC Members to Engage
 Patient advocacy groups have a key role to play in educating Navigators and In-
Person Assisters in serving exchange enrollees with special needs or chronic
conditions
 Key considerations in plan design for assisting patients
» Provider Access: Ensure patients’ physician(s), facilities of choice are in-
network
» Drug Cost-Sharing and Other Access Limitations: Understand formulary rules
for specialty drugs and biologics, including costs and utilization management
 NHC members should seek opportunities to partner with other stakeholders who
share the goal of maximizing exchange enrollment and promoting high levels of
appropriate plan choice

43. QUESTIONS?

44. If you have any questions or comments
about the National Health Council
and its work on behalf of patients,
the essential health benefits,
or enrollment in the exchanges,
contact us at info@nhcouncil.org.