I. Eligible Populations for Premium Assistance Programs

1. At what income level should individuals be eligible for subsidies? 

2. What methods should be implemented to minimize or eliminate crowd-out?

3. Should other conditions of eligibility be established for participation in the premium assistance program?

• Most support coverage up to 200% FPL.
• One supports up to 100% FPL, and one supports up to 300% FPL.
• Some support for coverage beyond 200 % up to 300% on a sliding scale.

• Most support the requirement that individuals must have been uninsured for at least 3 months.
• Some want policy to mirror CHIP, with CHIP allowable exceptions to the requirement.
• Some either support a longer period of uninsurance or an assessment of a longer period of uninsurance; e.g., 6 months to further minimize crowd-out
• Some do not want this requirement applied to those under 100% or 150% FPL arguing that research indicates crowd-out is not a factor in lower income levels, because the likelihood of having employer sponsored insurance is low.

Other ideas to minimize crowd-out

• Have employer participation requirements – may not have offered insurance for previous 12 months

• Make as simple as possible.
• Some said give priority to parents of Medicaid/CHIP enrolled children
• Some recommended requiring that dependent children of HOP adults must be insured or have applied for coverage in order for adults to be eligible.
• Some recommended consideration of a model which allows for a gradual transition period for individuals to fund their own coverage as incomes increase.
• One recommended considering other economic and demographic variables that impact available income and ability to pay for coverage.

II. Coverage Options (Part 1)

1.  Which qualified products should be eligible for purchase by enrollees? 

2.  What types of insurance packages can premium assistance be used to purchase?

3.  How will qualified carriers be chosen to participate in the premium assistance   program?

• Responses reflected a wide range of opinions.
• Many support TDI regulated options only; HMO and indemnity.
• Some specifically supported hospital-based coverage options.
• Many supported 3-share and local programs, standard commercial products, other coverage options.
• Some for and some against HSA options. Those against say that they do not work for low-income populations; those for say fully fund accounts at lower income levels.
• Some for and some against high deductible health plan option.
• Some support for broad array of options; some support for limited options, citing confusion for enrollees and administrative simplicity.
• Some said no limits on product options.

• Some support for range of options: basic, comprehensive and catastrophic based on consumer choice
• Some support State-defined benefit package, while others support the State setting minimum benefit standards
• Some say include mental health and substance abuse treatment
• Some support basic for everyone or catastrophic coverage for everyone
• Some say let the market decide
• Many include focus on primary and preventive care; don’t require cost sharing for these types of services; and one supported requiring preventive health coverage unless recipient actively opted out of coverage.
• Some support for benefit variations that can be locally driven and one recommendation that options not be limited to commercial market only.

• Most support choosing a limited number of carriers through a competitive process; some recommend a regional level competitive process.
• Some feel that HHSC should manage contracts.
• Some suggest certifying qualifying plans (i.e., Massachusetts “seal of approval”).
• One suggested consideration of the track record of carriers in selecting carriers for HOP. Health plans that have demonstrated deficiencies in enrolling sufficient provider networks should not qualify.

II. Coverage Options (part 2)

4. Should the number of coverage options available to consumers be limited?

5. What incentives could be established to assist small businesses in providing coverage?

6. Should other coverage options or considerations be included?

• Most support limited options, to avoid consumer confusion and administrative simplification (cite Florida as offering a confusing array of options)
• Some support unlimited menu of options

• Many support franchise tax incentives.
• Many support elimination of underwriting and guaranteed issue.
• Many suggested reinsurance to reduce premiums.
• Some support establishing “Connector” function, i.e., an entity to help administer the available plans, to support portability, and help ease employer administrative burdens for purchasing insurance. 
• Some support assisting small businesses in setting up Section 125 plans (in which employees can make tax-free contributions to insurance premiums).
• Some support eliminating minimum participation requirements for employers (current 75% required participation).
• Some support limiting premium increases over time.
• Some support allowing pooling for small businesses.
• Some suggested state contractors be required to provide insurance to employees.  One suggested offering preferential contracting for small employers who contract with state or local governments and offer employer sponsored insurance.

• Some said establish appropriate standards for 3-share programs.
• One supported requiring that university students obtain coverage through university plans with HOP subsidies for low-income students.
• Some recommended limiting risk through reinsurance or imposing an annual cap such as $20,000.

1. How should premium assistance levels be established?

2. What is the term of enrollment for premium assistance?

3. Should any other approaches be taken in establishing subsidy levels or duration?

• Many support premium assistance on a sliding scale based on income (e.g. full subsidy up to 100-150%).
• Many support cost-sharing limits like CHIP so premiums not required for lower-income individuals (under 100%-150% FPL)
• Some support subsidy level tied to a basic plan with enrollees contributing to a more comprehensive plan.
• Some support considering aggregate cap on premiums and cost sharing not to exceed 5% of income
• Some suggest that tiered benefits or cost-sharing could adversely affect persons with chronic conditions
• One said premium subsidy should be tied to age and income
• One suggested discounting the premium for parents who enroll their CHIP and Medicaid eligible children.
• One recommended that enrollees be required to contribute 10% of their annual income toward cost of coverage.

• Nearly all supported 12-month enrollment.
• One recommendation for 6 months.
• Some recommended options for purchasing benefits if no longer income-eligible for the subsidy, i.e., a buy-in at higher income levels.

• Some suggested the state could vary subsidy level based on healthy lifestyles.
• Some recommended incentive program for accessing primary and preventive care.
• Some have concerns about anticipated higher costs due to
  “pent up” needs that have not been taken care of, adverse selection, and underwriting restrictions
• Some said cost sharing should be avoided for low-income and chronically ill.
• One recommended time limit for program enrollment set by Legislature.

IV. Administration and Implementation

1. Given the large number of uninsured Texans and the time-limited nature of a demonstration waiver (5 years), how should the program be implemented to begin making subsidies available?

2. Given the funding available and the fact that the demand for subsidies may exceed initial funding, how should enrollment in the program be managed?

3. Based on the design principles, is there another approach that should be taken to implement the premium assistance program?

• Most supported phased-in approach and leveraging existing eligibility information.
• Some support inclusion of community based programs, 3-Share programs, or regional pilot programs, in Phase I.
• Some communicated that local communities better know their local populations and their needs

• Some support statewide first come, first served
• Some support priority given to parents of Medicaid/CHIP enrollees based on income determined by available funding.
• Many support providing first opportunity to lower-income adults or devise outreach and assistance to ensure enrollment is not a deterrent for most vulnerable populations
• Some support starting with programs already in place (e.g., 3-Share and other regional and local based programs).

• Many recommendations for state-funded reinsurance.
• Many support minimizing administrative burden for providers.
• Many support simplifying enrollment for enrollees
• Some recommend the program continue to use current state infrastructure
• Some suggest funding community-based ambulatory care, systems of evidenced-based care (e.g. DM and Electronic Health Records) and providing incentives for participants to use these tools.
• One placed emphasis on bilingual approaches and some placed emphasis on consumer education.