1. Nebraska Health Insurance Exchange Questionnaire

A health insurance Exchange is a central marketplace for health insurance that provides one‐stop shopping for individuals and small businesses to compare rates, benefits and quality among plans. The Exchange will also administer the new federal health insurance tax credits for those who qualify and make it easier to enroll in health insurance.

As part of our commitment to openness, transparency, and stakeholder engagement, we highly encourage all stakeholders to participate in our Health Insurance Exchange Survey in order to provide valuable input on the design of our potential Health Insurance Exchange. The following questions seek to gather preliminary feedback on key Exchange design and policy decisions. Additional written comments can be added to each individual question on the survey.

More information regarding the State's effort can be found at http://www.doi.ne.gov/healthcarereform/exchange/index.htm (please cut and paste)

Please enter your contact information below so we can follow up on any feedback. Answers are only required for the first two questions. Any comments provided will be considered confidential but may be used in the executive summary or analyst's reports without attribution to you or your organization.

In order to incorporate your input in a timely fashion, the Department requests that you complete the survey by July 15th. Thank you for your feedback.

* 1. Please enter your contact information below:

* 2. Are you a(n):

Employer Follow Up

* 3. How many people do you employ?

* 4. Who manages employee benefits for your organization? Please check all that apply:

Exchange Goals

* 5. A broad list of possible Exchange objectives is displayed below. Please select the principles that you think should guide the formation of Nebraska's Exchange, if the state chooses to create a state-based Exchange. Check all that apply.

Exchange Business Model

* 6. Exchanges have different business models that they can follow. These models are described in more detail below.

Which model do you think would work best for Nebraska?

* 7. Please offer any additional comments on the Exchange Business Model.

* 8. Do you have any suggestions for strategies that Nebraska could employ to increase competition in the health insurance marketplace?

Exchange Small and Individual Market Requirement Questions

* 9. The Affordable Care Act (ACA) establishes combined risk pools for the small group market in and out of the Exchange and individual market in and out the Exchange. States may also elect to merge the small group and individual markets. This would create one risk pool for individuals and small groups in or out of the Exchange. Should Nebraska merge the current small group and individual markets?

* 10. The ACA allows for carriers who offer dental only plans who cover pediatric dental benefits to sell dental only products for everyone within the Exchange. Should the potential Exchange offer other stand-alone benefit plans such as vision only plans?

* 11. Should the potential Exchange offer plans only available in specific geographic areas or should all plans offered in the Exchange have the requirement to be available statewide?

* 12. Exchange design will impact consumers who seek to purchase plans in the Exchange. If an Exchange design attracts primarily unhealthy participants then the Exchange plans will become more expensive and potential participants will be more inclined to purchase health plans sold outside the Exchange. Additionally, individuals may choose to wait until they become sick to purchase health insurance, which is known in the insurance industry as adverse selection. This will increase premium cost for everyone. Please indicate what preventive strategies you would support in the health insurance markets to help ensure the affordability of products sold within the Exchange.

  Support Don't Support Uncertain
1. Institute limited enrollment periods for the individual market
2. Institute limited enrollment periods for the small group market
3. Institute a waiting period of 30 days for covered services for the individual market
4. Institute a waiting period of 30 days for covered services for the small group market
5. Institute penalties for dropping coverage and then enrolling again when ill for the individual market
6. Institute penalties for dropping coverage and then enrolling again when ill for the small group market
7. Tie open enrollment periods to the enrollee's birthday

* 13. If a market for health insurance products exists outside the potential Exchange, it is possible that rules governing health plans (e.g. marketing, benefits, enrollment, etc.) in this market could be different than the rules in the Exchange.

Should the rules for insurers be the same for the markets inside and outside the Exchange?

* 14. Assuming that a health insurance marketplace exists outside of the Exchange, should health insurers be allowed to offer health plans in the outside market that are not qualified to be sold in the Exchange? (Check all that apply)

* 15. Assuming there is a market outside of the Exchange for health insurance, should health insurers be required to sell the plans they offer in the Exchange in the outside market?

* 16. Assuming an outside market exists, should the State require premiums for comparable products to be the same in the Exchange and in the outside market?

* 17. Should all health insurers who sell in the State be required to offer their products in the Exchange?

* 18. The potential Exchange will be a new forum in which to purchase insurance. Should ACA-governed insurance products, known as "qualified plans" in the Exchange, continue to be available for purchase outside the Exchange?

* 19. Requiring health insurance carriers who offer plans in the potential Exchange to offer plans in both the individual and small group markets could increase the chance that an individual could keep the same coverage if their employment circumstances change. Should health insurers be required to offer Exchange plans for both the individual and small group markets?

* 20. Should plans offering in the Exchange be subject to additional State certifications requirements pertaining to quality and cost of care?

* 21. How should open enrollment be conducted in the individual market?

* 22. In the individual market, should Exchange plans be limited to re-pricing their products only at enrollment/renewal?

* 23. In the small group market should Exchange plans be limited to re-pricing their products only at enrollment/renewal?

The Exchange and Medicaid

* 24. Should the State provide premium vouchers to Medicaid-eligible individuals to buy commercial health coverage products in the Exchange?

* 25. Should Medicaid-contracted health plans be required to offer a comparable commercial product in the Exchange to aid individuals transitions between Medicaid and Exchange products?

* 26. States may offer premium vouchers to parents with children eligible for the Children's Health Insurance Program (CHIP) to cover the cost of the dependent coverage. These premium vouchers could allow for the purchase of family coverage through the Exchange so that the family unit could be covered by a single plan.

Should Medicaid provide premium vouchers to parents of CHIP children to aid in the purchase of family health coverage product in the Exchange?

* 27. The ACA gives states the ability to operate a "Basic Health Plan" for individuals between 133% and 200% of the federal poverty level (FPL). A state can use 95% of the tax credits that would have been available to these individuals for Exchange coverage to operate the "Basic Health Plan." Should Nebraska consider establishing a Basic Health Plan?

Exchange Data and Consumer Needs

* 28. What type of data will be important for consumers to have when making health plan selection decisions? Please rate the below on a 1 to 5 scale.

  1- Not Important 2 3 4 5- Very Important
1. Premium
2. Deductible, or the amount of covered expenses the enrollee pays in full each year before plan benefits begin
3. Co-payments, the fixed amounts paid by the enrollee for each office visit of pharmacy prescription filled
4. Co-insurance, a payment for services where the enrollee's share of payment is based on a percentage of total cost
5. Yearly maximum out-of-pocket expenses, the total of deductible, co-payments, and co-insurance than an enrollee could be responsible to pay over a year
6. Plan quality (Exchange Ranking of Insurance Plans)
7.Claims denial rate
8. Average cost of specific services
9. Health plan enrollee satisfaction
10. Network of available doctors and facilities
11. Doctor quality
12. Patient satisfaction by doctor
13. Average appointment wait times
14. Hours

* 29. Should Exchange plans be required to provide claims data (subject to the appropriate privacy requirements) to the Exchange or other entity so that cost and quality data can be made available to the public?

* 30. Please offer any comments on the Exchange and quality and cost control initiatives.

Small Business Health Option Programs (SHOP) Exchange

An Exchange serves both the individual and small group markets. For the small group market the Exchange is called the Small Business Health Option Programs (SHOP) and offers health plans that businesses can purchase for their employees.

* 31. For the small group market, the groups may be defined as 1-50, 2-50, 1-100, or 2-100 employees. What should the small group definition be for initial Exchange participation in 2014?

* 32. State are allowed to open Exchange eligibility to large employers starting in 2017. Should large employers (greater than 100 employees) be allowed to participate in an Exchange in 2017?

* 33. An Exchange could offer defined contribution plans, in which employers provide a fixed contribution to their employees' health plans and the employees use the employer contribution to select the plans they deem appropriate for their needs.

Should the Exchange consider offering defined contributions for employers?

* 34. If a plan is deemed qualified according to federal standards it is then placed in a benefit tier based on its' actuarial value. For example, bronze plans offer the most basic benefits and platinum plans offer the richest benefits.

If the Exchange offers defined contribution plans, should employees have a choice among all possible plans across benefit tiers (Bronze, Silver, Gold, etc.), be limited to all possible plans within a benefit tier, or be limited to employer plan selections?

* 35. Should employers purchasing coverage in the Exchange be required to make a minimum contribution towards their employees' health plans?

* 36. Should employers purchasing coverage for their employees in the Exchange be required to have a minimum percentage of their employees participating in the plan?

* 37. Should the Exchange consider offering Internal Revenue Code 125 (Cafeteria Plans) so that employees may, on a pre-tax basis, purchase their insurance?

* 38. Instead of small businesses sending payments to carriers, an Exchange can collect employer, employee, and other (subsidies, etc.) premium payments and distribute them to the appropriate health carrier. This would allow for multiple employers to contribute to a single plan on behalf of an employee and their family. This is referred to as premium aggregation.

For small employers, should the Exchange collect premium contributions from employers, employees and other sources and distribute them to health insurers?

Exchange Administrative Functionality Questions

* 39. Should the Exchange provide the ability to shop, compare, and purchase health plans? Or, should the Exchange only provide comparison data and direct buyers to the individual insurers to purchase health plan?

* 40. In the individual market, should the Exchange collect premium contributions from individuals and distribute them to health insurers?

* 41. In the individual market, should the Exchange have the functionality to aggregate premium contributions from multiple sources (individuals, part-time employers, subsidy contributions, etc.) and distribute lump sum premium payments to insurers?

Exchange Financing Questions

* 42. An Exchange must be self-sustaining by 2015. This means that after 2015 the federal government will not provide funds to support the operations of a State's Exchange. How should the Nebraska Exchange be financed? (Choose one or more)

Exchange Insurance Questions

* 43. Were you involved in the purchasing decision of your current health insurance coverage?

* 44. How well do you understand your current health insurance coverage?

* 45. If you have a question or need assistance with your health insurance coverage, who do you contact?

* 46. If you need assistance with comparing insurance options how would you prefer to receive it?

* 47. Should those who provide support in the Exchange health insurance enrollment process hold a certification or license to counsel and advise consumers?

Exchange Navigator Questions

* 48. The ACA requires an Exchange to establish a "Navigator" program. Navigators are required to:

1. Conduct public education activities
2. Raise awareness of the availability of qualified health plans
3. Distribute fair and impartial information concerning enrollment in qualified health plans
4. Distribute fair and impartial information on the availability of premium tax credits and cost-sharing reductions
5. Facilitate enrollment in qualified health plans
6. Provide referrals to any applicable office of health insurance consumer assistance or any other appropriate State agencies
7. Provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Exchange or Exchanges.

Who should hold the Navigator positions in Nebraska's Exchange? (Check all that apply).

* 49. How should the Navigators of the Exchange be compensated? (Check all that apply).

* 50. Should Navigators be trained to help people enroll in public programs (e.g. Medicaid) as well as private health plans?

* 51. Should Navigators be licensed?

* 52. Should compensation for Navigators and/or brokers be required to be the same inside and outside of the Exchange?

* 53. What should the role of brokers be relative to the Exchange?

* 54. What are ways to prevent agents/brokers from having incentives to steer individuals and businesses away from the Exchange?

* 55. Should the State of Nebraska create a state-based Exchange, participate in a regional Exchange, or allow the Federal government to create a Federally operated Exchange for the State?

Additional Comments

* 56. Please add any additional comments:

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