Health Insurance Exchange



Starting October 1st, Idaho will begin its hotly debated Health Insurance Exchange website. The state is hoping the Idaho Health Insurance Exchange (IHIE) will be a tool and resource individuals, families, and small businesses will use in order to make an accurate comparison of competitively priced health insurance plans. Since extremely partisan politics played a role in the creation of this state based website, I was wondering if the site would be a good resource/tool for me or not. I can’t promise to leave me own personal politics out of this post but I will try.

Before I continue I should point out that I am NO WAY qualified to make recommendations for anyone but myself! This post is strictly meant to be a hypothetical exercise for me in the hopes of helping others to navigate their own particular states Health Insurance Exchange.

The parameters of my hypothetical exercise are as follows. I am a 30 something that has had 7 surgeries since 2003 and is currently battling chronic Gout and Osteoarthritis. My income falls in the $15-20/hour range, own my own home, and don’t smoke. Due to the swelling and pain associated with these types of arthritis, I need a plan with a prescription drug component. I’m single, no dependents, work out 2-4 a week, and work full-time.

History of Idaho’s Exchange

In 2012, the U.S. Congress passed the Patient Protection and Affordable Care Act (ACA) or Obamcare (as conservatives are fond of calling it) requiring the establishment of a health insurance exchange in each state by October 1st, 2013. The idea behind the legislation was to create an online market place where individuals could go to get “apples to apples” comparison of insurance plans offered by private insurers. This market based tool would then help consumers select from competitively priced health insurance plans. Idaho’s Health Insurance Exchange, in particular, hopes that all uninsured citizens will now have access to plans that have a similar level of benefits as employer based plans and cover all essential benefits.

Idaho believed that with a state-run Exchange it could prevent increase federal government involvement in its affairs. More local control would allow Idaho stakeholders the opportunity to participate in the design and administration of the exchange while also maintaining local regulatory authority. The IHIE was created to be governed by a 19 member board of Idahoans and is separate from the state of Idaho.

From what I’ve been able to gather so far, most so called “state-run exchanges” have a very similar history to Idaho’s exchange. Since politics played a huge role in this debate, it was easier to “sell” local constituents on the idea of local control. Although each state is different, the goals and structure of these “local” exchanges seem to be fairly similar. Please check with your local Department of Insurance’s if you are interested in learning more about the history of your states exchange.

Key Terms and Definitions

Essential Health Benefits of the Affordable Care Act-Starting in January of 2014, health insurance plans in the individual and small group markets (includes plans both on and off the exchange) must offer a core package of items and services which include:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
    • Pediatric services, including oral and vision care

Essential Health Benefits of the Affordable Care Act must be covered with no annual dollar limits or lifetime maximums. These Essential Health Benefits must be included in individual and small employer plans as they renew in 2014. Any individual or small employer group policy that was issued prior to March 23, 2010 does not have to comply with all of the new requirements of the Affordable Care Act. This requirement is designed to match the benefits offered by a “typical employer plan” in each state.

Idaho’s Benchmark Plan-States and insurers have flexibility to adjust what is included by plans in their states, as long as the level of coverage meets or exceeds the state’s benchmark plan. The benchmark defines what benefits must be covered, but it does not determine cost-sharing levels. Carriers will determine the cost-sharing features for the products they offer, and these will be based on actuarial values for different metal level plans (bronze, silver, gold and platinum) as defined by the ACA.

Idaho’s “Benchmark Plan” is the Blue Cross of Idaho Preferred Blue PPO plan, with supplements from the Federal Employee Dental/Vision Insurance Program for pediatric dental and pediatric vision. All plans filed to be sold in Idaho will be compared to – and must match – the Idaho Benchmark Plan with some limited variation.

The Idaho Benchmark Plan includes Idaho state-required benefits as follows:

                                               i.     delivery and all inpatient services for maternity care (maternity minimum stay)

                                             ii.     preventive care/screening/immunization (mammography coverage)

                                            iii.     reconstructive surgery (breast reconstruction, if mastectomy is covered)

                                            iv.     congenital anomaly, including cleft lip/palate

Chronic Disease Management-An integrated care approach to managing illness which includes screenings, check-ups, monitoring and coordinating treatment, and patient education. It can improve your quality of life while reducing your health care costs if you have a chronic disease by preventing or minimizing the effects of a disease. Chronic Disease and Management (as defined by Wisconsin)- In general terms, chronic diseases are defined as illnesses that last a long time, do not go away on their own, are rarely cured, and often result in disability later in life (adapted from McKenna and Collins, 2010).

The goals of chronic disease prevention and management are to prevent disease occurrence, delay the onset of disease and disability, lessen the severity of disease, and improve the health- related quality and duration of the individual’s life (adapted from Doll, 1985). The line between what constitutes prevention and management is somewhat blurred. However, prevention efforts traditionally involve interventions performed before the clinical onset of disease or early in the course of disease, while management efforts may occur later in the disease course and are often focused on reducing the undesired consequences of diseases (adapted from McKenna and Collins, 2010).

Importance of the Focus Area

Chronic diseases – such as heart disease, stroke, cancer, diabetes, asthma and arthritis – are among the most common and costly of all health problems in the United States (National Center for Chronic Disease Prevention and Health Promotion, 2009b). The good news is that chronic diseases are also among the most preventable diseases.

Currently, seven of the 10 leading causes of death in Wisconsin and the United States as a whole are due to chronic diseases, accounting for approximately 2 out of every 3 deaths annually (McKenna and Collins, 2010; Wisconsin Interactive Statistics on Health, 2009). In addition, over 80 percent of the $2 trillion spent on health care in the United States each year goes toward treatment of chronic diseases (McKenna and Collins, 2010). A significant portion of this care is publicly funded. Medicaid spending has grown rapidly in recent years and is placing a significant burden on state budgets (National Center for Chronic Disease Prevention and Health Promotion, 2009a).

Four modifiable health risk behaviors— unhealthy diet, insufficient physical activity, tobacco use and secondhand smoke exposure, and excessive alcohol use — are responsible for much of the illness, suffering, and early death related to chronic diseases. There are proven, evidence- based strategies that can be used to combat chronic diseases, and when the focus turns to addressing those four modifiable risk factors, a reduction in the number of people living with and dying from chronic diseases in Wisconsin can be expected. The World Health Organization (2005) estimates that by eliminating the risk factors leading to chronic disease, at least 80 percent of all heart disease, stroke and type 2 diabetes would be prevented, as would over 40 percent of all cancers.

New Codes to Report Complex Chronic Care Coordination-By Sarah Serling, CPC, CPC-H, CPC-I, CCS-P, CCS, ICD-10-CM/PCS Trainer
December 05, 2012

Beginning in 2013, physicians will have new codes to report complex chronic care coordination (“CCCC”) services. Patients needing complex care coordination often have multiple providers treating multiple chronic medical conditions and may have significant functional deficits. In addition to psychiatric and behavioral co-morbidities such as dementia or substance abuse, access-to-care challenges and lack of social support may complicate care of these patients.

The new complex chronic care coordination services CPT codes were created so physicians and other qualified health care professionals could bill for time spent coordinating different services and medical specialties needed to manage the complex nature of the patient’s medical condition, psychosocial needs and activities of daily living.

Three new CPT codes (9948799489) for complex chronic care coordination provided by physicians, other qualified health care professionals and clinical staff to a patient with complicated, ongoing health issues living at home or in a domiciliary, rest home or assisted living facility.

99487 Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with no face-to-face visit, per calendar month

99488 Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month

99489 Complex chronic care coordination services; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)

The complex chronic care coordination services described by these codes involve clinical staff implementing a plan of care established and directed by a physician or other qualified health care professional. These codes include all non–face–to–face complex chronic care coordination services and may include one face–to–face office or other outpatient, home, or domiciliary evaluation and management visit related to care for the patient’s chronic conditions.

CCCC codes 9948799489 may only be reported once per calendar month. A parenthetical note following the CCCC codes indicates several excluded codes from both the E/M and Medicine sections. Codes 9948799489 cannot be reported during the same month as any of the excluded codes. Extensive section guidelines were also added to instruct on the use of the new codes.

It is important to note that for 2013, Medicare considers CPT codes 99487, 99488, and 99489 bundled services and will not reimburse for them. At this time, CMS believes these services are appropriately bundled into the services to which they are incident and as such, are not separately payable. On an interim basis for CY 2013, CPT codes 99487, 99488, and 99489 are assigned a status indicator of B (Payments for covered services are always bundled into payment for other services). Fortunately, CMS indicated in section II.H of the 2013 Physician Fee Schedule final rule, they intend to consider codes for complex chronic care coordination services as part of an overall strategy to support primary care and care management and to explore approaches to promote primary care within a fee-for- service payment structure.

What to Expect from Idaho’s Exchange?

Health insurance plans sold on Idaho’s exchange will feature 4 different levels of coverage or “metals”; Bronze, Silver, Gold, and Platinum. Platinum plans will have the highest monthly premiums but the lowest out-of-pocket costs. Basically, the plan will pay 90% of costs for things like my arthritis but will have the highest premium. By comparison, a Bronze plan will probably be the cheapest but only pay 60% of my medical care costs.  Silver and Gold plans will pay 70 and 80% of medical costs respectively and cost somewhere in between Platinum and Bronze plans.

Unfortunately, specific plans won’t be available on IHIE until October 1st, 2013. However, I did find that people who earn up to 400% of the poverty line (sadly this includes most of Idaho and myself) would be eligible for subsidies if they purchase insurance from the exchange. Using a Subsidy Calculator which I found on The Henry J. Keiser Family Foundation’s website, I was able to get a good idea of the amount of subsidies that I would be eligible for.

Based on a Silver Plan

  $15.00/hr = $31,200 a Year $20.00/hr = $41,600
Household Income in 2014: 272% of poverty level 362% of poverty level
Unsubsidized annual health insurance premium in 2014: $3,761 $3,761
Maximum % of income you have to pay for the non-tobacco premium, if eligible for a subsidy: 8.67% 9.5%
Amount you pay for the premium: $2,706 per year

(which equals 8.67% of your household income and covers 72% of the overall premium)

$3,761 per year

(which equals 9.04% of your household income and covers 100% of the overall premium)

You could receive a government tax credit subsidy of up to: $1,054

(which covers 28% of the overall premium)


(which covers 0% of the overall premium)

Just as a side note, small businesses can use the exchange too in order to find an accurate comparison of certified health plans for their employees. Idaho defines a small business as up to 50 employees. I could not find if that means 50 full-time, part-time, or a mix of both however. Agents and Brokers cans till serve as a primary point of contact for small businesses but they can also select plans directly from the exchange if they so choose.

My Conclusion

First, I would like to remind everyone that I am no way qualified to help others pick health insurance plans. The purpose of this post is to give you some insight into Idaho’s Health Insurance Exchange that is probably very similar to your own states exchange. I’m happy to help or answer any questions you might have about this post but under no circumstances will I recommend a plan for you. Please keep that in mind.

After researching Idaho’s Health Care Exchange, I can report that I’m hopeful that the Affordable Care Act can help patients like me who are suffering with arthritis and chronic pain. The Essential Health Care Benefits, as defined by the federal government, seems to finally define arthritis as a Chronic Condition instead of just an “old person problem”. By including arthritis as a Chronic Condition, more of my care and maintenance should be covered by insurance instead of my checkbook. This will mean less out-of-pocket expense for people like me which would in turn means I can spend more money on healthy supplements, organic/clean food, and equipment I might need in order to remain active.

I do see two potential problems with the Affordable Care Act though. First, if “healthy people” opt to pay the penalty instead of purchasing health insurance then premiums would increase dramatically which would make health insurance cost prohibitive. We need all “healthy people” to purchase insurance in order for the plans to remain affordable for people like you and me. The second potential problem is for people suffering with multiple arthritic disorders like Rheumatoid Arthritis and AS. These plans seem to be designed to catch most patients, not the ones whose costs can be in the $100,000 plus range.

Despite these potential problems, I would definitely be interested in shopping for health insurance on Idaho’s new exchange. With the potential subsidies I’m eligible for and with having a steady full-time job, I don’t think the cost of the premiums for any of the plans would be prohibitive since I fall within the $15 to $20 an hour income range. Since arthritis is such a degenerative type of disease, it is almost a necessity that I have some form of health insurance. As of right now it does seem like the Affordable Care Act and Idaho’s Health Insurance Exchange will be helpful tool for me in comparing health insurance plans that would meet my particular needs.

P.S. As Idaho’s Exchange gets closer to going live I will be watching for any problems or changes to my initial conclusion. If something changes that might affect me one way or another I will be sure to let you know. In other words, stay tuned!!!



Health Insurance Exchange, Idaho, Arthritis, and Me — No Comments

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