Affordable Care Act Symposium December 16, 2013

1. Affordable Care Act SymposiumDecember 16, 2013 Working together for CNMI healthcare reform 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

2. What we hope to gain today? • Get the public and private sectors on the same page regarding the changes to the CNMI healthcare system • Provide status updates on implementation efforts by the Dept. of Commerce • Hear perspectives from healthcare stakeholders (provider and insurance carrier) • Collaborate on mitigating the impacts of the federal healthcare reform to strengthen our healthcare system, not destabilize it 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

3. Healthcare Reform in the CNMI Making the Affordable Care Act work for us 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

4. In this presentation • What is the Affordable Care Act? • How does it affect the CNMI? • What can we do to mitigate the impacts? 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

5. Brief Background of the Affordable Care Act (ACA) • In March 2010, President Obama signed comprehensive health reform, the ACA into law. • This law was a bipartisan resolution to address the nationwide problems with health care. • The law does not create health insurance, but regulates it. • The ACA also includes provisions for improving quality and lowering the cost of health care. 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

6. Why was the Affordable Care Act passed? 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

7. A Broken Health Care System In 2009, the U.S. spent moreon health care Per capita ($8,608) Percentage of GDP (17.9%) than any other nation (WHO) 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

8. A Broken Health Care System In 2006, the US ranked 39th in infant mortality, 43rd for adult female mortality (42nd for male) and 36th for life expectancy (WHO) 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

9. A Broken Health Care System 2003 to 2009 Premiums for businesses and employees jumped 41% across the states Per person deductibles jumped 77% (2010, The Commonwealth Fund) 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

10. A Broken Health Care System • Between 2001 and 2007, the percentage of bankruptcies due to medical problems increased 49.6% (Medical Bankruptcy in the United States, 2007: Results of a National Study. American Journal of Medicine). • An estimated 45,000 Americans die annually due to a lack of health insurance (2009, American Journal of Public Health) • In 2009, Families USA estimated that the extra cost of care for the uninsured added $1,000 to family insurance premiums. 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

11. A Broken Health Care System 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

12. Market Reforms Effective in 2010, insurance companies can’t: • Deny coverage to young adults on their parent’s plan until they are 26 • Raise premiums without justification -Grants awarded for CNMI rate review • Deny coverage of children because of a pre-existing condition • Rescind coverage for no good reason • Prohibit a consumer from filing an appeal on a coverage denial 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

13. Market Reforms • Alcohol Misuse • Blood Pressure • Cholesterol • Colorectal Cancer • Depression • Breast Cancer • Obesity • Tobacco Use and cessation interventions • Diabetes (Type 2) • “Well woman visits”   • Diet counseling  • Immunization vaccines   • Contraception such as birth control pills (Not abortions) • Domestic and interpersonal violence screening and counseling for all women • Autism screening for children at 18 and 24 months • (Non-grandfathered plans) Effective in 2010, insurance companies can’t: • Charge any cost sharing or deductibles for certain in-network preventive care services 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

14. Preventive Care is crucial to public health and the economy of the CNMI • In the CNMI, over 11% of adults age 25+ have diabetes (Diabetes in the Indigenous Population of the Commonwealth of the Northern Mariana Islands. Pacific Health Dialog. 1999;6(1):39-44.) • Some estimates have put this number at over 25% (Tanapag Study, 2001. CNMI Tobacco, Diabetes, Obesity, HPTN 2008) • In 2010, a regional health emergency was declared in the US-affiliated Pacific Islands due to the epidemic of non-communicable diseases. (Pacific Island Health Officers Association) 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

15. Market Reforms In 2011 and 2012, over $380,000 was rebated to CNMI residents because of the MLR rule. Effective in 2011, insurance companies can’t: • Spend less than 80% of premiums collected on medical claims, otherwise they must reimburse the difference to their enrollees (Medical Loss Ratio) - Keeps insurers accountable for how they spend your money 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

16. Health Insurance Reform • On October 1st, 2013 health insurance marketplaces, or “exchanges” opened in the US mainland. • These exchanges are used to compare coverage and enroll in health insurance. • Due to the tax credits and subsidies offered in these exchanges (up to 400% FPL), the CNMI could not afford this. • All US territories chose to use the one-time lump funding to expand Medicaid, rather than establish an exchange. 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

17. For Plans or Policies Starting Jan. 1, 2014 or later Essential Health Benefits (EHB) categories are: Ambulatory Patient Services Emergency Services Hospitalization Laboratory Services Maternity and Newborn Care Mental Health and Substance Abuse Disorder Services Pediatric services, including Oral and Vision Prescription Drugs Preventive and Wellness Services and Chronic Disease Management Rehabilitative Services These must be provided to the covered person according to the EHB benchmark plan, Blue Cross Blue Shield Standard Option and Pediatric Vision services of FEDVIP • Health insurance issuers must include coverage which • Incorporates defined essential benefits • Limits cost-sharing on these “EHBs” 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

18. For Plans or Policies Starting Jan. 1, 2014 or later • Insurance carriers offering coverage in the individual and small group market may not charge discriminatory premium rates. Rates can only vary according to: - Family Size - Geographical Area - Age - Tobacco Use • Insurance must be guaranteed available (during certain open enrollment and special enrollment periods) • Insurance must be guaranteed renewable 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

19. For Plans or Policies Starting Jan. 1, 2014 or later • No waiting period can exceed 90 days • Annual limits on essential health benefits are prohibited • Health insurance carriers may not impose a preexisting condition exclusion or discriminate based on health status. 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

20. Does the new healthcare reform include the CNMI? • The federal law is expanded to the territories, but only in pieces. • The goal of the ACA is for every American to have affordable, comprehensive health insurance • To do this, three major components of the law become a metaphorical “three-legged stool” 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

21. The “three-legged stool” • Requires employers to offer sponsored health insurance coverage or pay a penalty. Tax credits are available for small businesses. 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

22. In the Territories.. 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

23. Concerns of the impacts of the ACA in the CNMI • Risk “Mitigators” are not extended to the territories • Insurance carriers risk insuring only the very sick. This raises premiums and makes coverage unaffordable, so even fewer are covered. • The benchmark plan is costly and too rich in benefits for the CNMI • Possible collapse of the insurance market 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

24. Benefits the ACA brings to the CNMI • Prior to the ACA, the CNMI Insurance Division had virtually no regulatory power over the rates and forms of health insurance. • Now we have a benchmark for insurance regulatory framework • Additional Medicaid funding • Pricing transparency and consumer advocacy • Market reforms • Keeps insurers accountable for premium dollars • Opportunity to reduce the number of uninsured and decrease CHC receivables 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

25. What can we do to mitigate the impacts? • Local action: • Pass laws to reduce abuse of guaranteed availability • Allow carriers to only guarantee issue coverage during limited enrollment periods • Tailor essential health benefits to suit the needs of the CNMI • Improve access to public assistance: Presumptive eligibility for Medicaid, Create public assistance enrollment for multiple programs • Increase prevention awareness/Work to reduce NCDs • Pass laws for Employer/Individual responsibility to have coverage 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

26. Where does the Consumer Assistance Program fit in all this? • Assist with the filing of complaints and appeals • Collect, track and quantify problems • Answer health care questions, explain health care coverage options • Educate the public on health care issues and consumer rights • Vigorously advocate on behalf of the consumer and to influence policy decisions and local legislation 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services

27. Health care consumers need to know how to protect themselves from unfair and illegal business practices. The CAP helps educate consumers to advocate for themselves. Contact the CAP office to get help understanding your rights as a health care consumer Website: cnmicap.wordpress.com Email: advocacyoffice@commerce.gov.mp Phone: 670-664-3005 2013 CNMI Consumer Assistance Program Presentation made possible by a grant from the U.S. Dept. of Health and Human Services