New 2013 Montana legislation

Montana Health Insurance Updates
Montana HealthCare Forum
Presented by
Commissioner Monica J. Lindeen
Commissioner of Securities and Insurance
Montana State Auditor
November 4, 2013
2013 Montana Health
Insurance Legislation
• Rate Review for Health Insurance—HB 87
• Patient-Centered Medical Home Program—SB
• Cancer Clinical Trials—SB 55
• Network Adequacy for PPO’s—HB 544
• Navigator/assister/producer training and
certification—HB 250
State-based Rate Review – HB87
• The CSI introduced a bill to the 2013 legislature to
create effective rate review authority for Montana.
• House Bill 87 (sponsored by Rep. Welborn) passed
and is now law.
• For the first time, the Montana insurance
commissioner has rate review authority.
• Montana has taken back rate review authority from
the federal government.
Rate Review
• In 2014, the ACA requires that adjusted community
rating apply to the individual and small employer group
• Issuers may not vary rates for individuals or small groups
based on health status or claims history
• Issuers must maintain a single risk pool and may vary
rates based on:
 Age (3:1 maximum)
 Tobacco use (1:5:1 maximum)
 4 geographic areas in Montana
Benefits of Rate Review
• Montana consumers have already benefited:
– One company lowered rates by 7 percent.
– A second lowered rates by 22 percent.
– A third company lowered rates by 66
Patient-Centered Medical Homes – SB84
• A Patient-Centered Medical Home (PCMH) is a
model of health care delivery that emphasizes
primary health care, coordinated care and
• In the PCMH model, insurers pay an incentive based
on quality of care, rather than quantity.
• SB 84 establishes standards and structure for a
statewide PCMH program.
• SB 84 requires CSI to adopt rules to implement
provisions of the law.
Implementing the
Montana PCMH Act
• Administrative rules were published at the end of
• Appoint the stakeholder council on November 8.
• Establish a process for recognizing which accrediting
organizations meet Montana’s standards.
• Begin qualifying practices and payers who meet the
decided standards in December.
• Educate the public and promote PCMH across
• Working now to incorporate Montana specific
Cancer Clinical Trials
Senate Bill 55
• Passed by the 2013 Montana legislature to clarify
coverage of routine costs for patients in approved clinical
trials must be covered.
• Went into effect immediately upon passage.
• Helps remove insurance uncertainties for doctors and
patients, allowing them to focus on fighting the disease
instead of coverage for routine costs.
• Addresses confusion and inconsistency in coverage of
routine care patients receive when undergoing a clinical
SB55 Implementation
• Note that the state law covers cancer only, but the ACA has a
similar provision that covers “all life threatening diseases.”
(effective 1-1-14)
• CSI is still noticing insurance denials of routine care claims. When
we explain the law to the company, they pay the claim.
• CSI will be issuing guidance to insurers soon to remind them of
the law.
• The advisory council developed an Oncology Clinical Trial
Treatment Notification Form.
– The form is being finalized and is intended to be set as a statewide
standard for communication on trials between providers and payers.
– CSI will continue education like today to the provider and payer community
to ensure the greatest benefit of the law to Montanans.
Network Adequacy – HB544
• A new network adequacy law in Montana was effective October 1,
2013. Most “network-type” health insurance plans, including
dental and vision, sold in Montana are “PPO” plans.
– The consumer’s cost-sharing is increased if he/she seeks
coverage from “out-of-network” healthcare
providers. Consumer cost-sharing is substantially reduced or
even eliminated if that consumer seeks healthcare services “innetwork.”
• The new law says that a provider network is deemed adequate if
it includes 90 % of the hospitals and 80 % of the healthcare
providers in the state.
• Below that threshold percentage, the commissioner
may “determine” a network to be adequate.
Network Adequacy cont.
• Below that level, a maximum differential is applied: no more
than 25 % cost-sharing difference that the consumer pays for
out-of-network services.
• The commissioner will disapprove a network plan as
“misleading” if there is no viable network.
• Cost-sharing differences between in and out-of-network are
significant—as much as four times higher. Consumers should
always check the insurer’s list of in-network providers before
they choose a health plan.
• Many of the benefits of the ACA are based on “in-network”
costs only.
Assistor State Certification– HB250
• All navigators, Certified Application Counselors
(CACs), and Certified Exchange Producers (CEPs)
must complete federal and Montana-specific
training be certified.
• CEPs must complete federal and state training to
sell products through the marketplace.
• CSI developed state-specific training materials.
Navigators must pass a background check and
take a test.
• CSI has a list of all certified navigators, CACs, and
agents on
Navigators and CACs
The ACA allows for two new consumer
assistance roles
• Navigators – contracted through grants from
HHS, responsible for performing outreach and
education, as well as enrollment assistance
• Certified Application Counselors – not paid by
exchange or federal grants—only offering
enrollment assistance
• Intended for current employees of medical providers and
community groups
Navigators and Agents
Similarities and Differences
• Both navigators and agents help consumers by
providing marketplace enrollment assistance.
• Navigators operate only within the
• Unlike agents, navigators cannot be
compensated in any way by insurers.
• States cannot require that navigators be
licensed producers, but they do need state
certification and training.
• Navigators and CACs may NOT recommend
specific insurance products.
HB250 Implementation
• In addition to their federal training, CSI
required an online state training for all 3 types
of assistors.
• CSI created to 90 minute webinars, both were
required for CACs; one was required for
• Weekly calls with Navigator groups.
• CSI is a continuous resource for CACs and
• Ongoing regulation of all 3 roles.
Certified Assistors
as of October 25, 2013
• Certified Application Assistors: 69
• Navigators: 26
• Certified Exchange Producers: 291
Montana Specific Training Included:
• Montana specific information on Medicaid and Healthy Montana Kids
• American Indian ACA benefits
• Montana specific privacy laws
• Unlicensed producer activity and the consequences
• Background information on plan design structure and how to choose a
• Deductibles and other cost-sharing
• Financial and health considerations
• Network Adequacy
• Prescription drug formulary
• Summary of Benefits and Coverage
• Multi-State Plans
• Autism and Mental Health Parity
• Stand-alone dental plans
• How to help people who aren’t eligible
Affordable Care Act
• Montana’s federally built, federally maintained
Marketplace website is not working properly.
•, visited by
more than 11,000 individual Montanans.
• We’ve answered nearly 1,000 questions from our
Ask Away site.
• Our office has hosted dozens of town hall events
to explain the law.
Adjusting to Marketplace
• Continue to do outreach and education.
• Work with assistors to adapt to problems and help
• Answer questions through the website.
• Montana website made more shopper friendly with a
calculator and charts on plan structure and cost
break down for people to view without having to go
• I met with an HHS official just last week to tell my
concerns and find out when a fix is expected.
Montana is a Plan Management State
for the Marketplace
• The CSI works with the federally facilitated
marketplace to alleviate duplication and save
consumers time and money.
• This coordination helps preserve the state regulation
of health insurance.
• CSI’s plan management duties includes:
– Recommending qualified health plans to the federally
facilitated marketplace.
– Using rate review authority to review health insurance
rates and their benefits.
– Monitoring insurance companies for compliance with state
and federal law.
Call my office 1-800-332-6148
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