Health Insurance Exchange - A Review of the Basics

Transcription

1 Health Insurance Exchange An Overview of the Basics Gail Kocher, BCBSA Sheila Cooper, CSG Government Solutions

2 Agenda Health Insurance Exchange: A Review of the Basics Federal Requirements Functions of an Exchange Federally Facilitated, State-Based, State-Based Partnership review of models Timeline

3 Federal Requirements Health Insurance Exchange Rules Patient Protection and Affordable Care Act (ACA) rules governing the Exchange can be found primarily in three parts: Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers 45 CFR Subparts 155, 156, and 157 Medicaid Program Eligibility Changes under ACA found in 42 CFR Subparts d ,435, and 457 Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment found in 45 CFR Part 135

4 Federal Requirements Health Insurance Exchange ACA created the ability for state s to establish a state-operated Exchange entity or elect (default) to a federally-operated Exchange The primary functions of the Exchange include: Eligibility and enrollment for Medicaid Eligibility and enrollment for Individuals Eligibility and enrollment for Small Business Health Options Program (SHOP) Plan Management Financial Management Consumer Assistance for the Exchange

5 Federal Requirements The Health Insurance Exchange Entity An Exchange entity must be one of the following: An incorporated n on-profit entity with demonstrated experience on a State or regional basis in the individual and small group health insurance markets and in benefits coverage and not be a health insurance issuer The State Medicaid agency Other State agency An Exchange that is a non-profit or an independent State agency must have a governing board with prescribed board member composition and principles.

6 Federal Requirements Eligibility and Enrollment for Individuals The Exchange will determine individual eligibility for advance premium tax credits and cost-sharing reductions ( insurance affordability programs ) Eligibility for insurance affordability programs must also use MAGI rules for income The Exchange must follow Federal rules for verification of application data Use of federal Hub envisioned for citizenship, residency, and income data elements Data matching rules On-line, real-time verification is envisioned i Provides latitude for State to elect self-verification for some data elements Once eligibility is determined, the individual is enrolled in a Qualified Health Plan (QHP)

7 Federal Requirements Eligibility and Enrollment for SHOP The Exchange requires states to establish SHOP Exchanges to creates to help small employers find and purchase health insurance for their employees, to assist qualified employers, and to facilitate the enrollment of qualified employees into qualified health plans (QHP s) The design of the SHOP exchange encompasses many features and policy considerations that make it distinct from the individual exchange including: The SHOP Exchange must bill employers The SHOP Exchange must collect premium payments The SHOP Exchange must make payments to QHP s for all enrollees States face challenges developing successful SHOP exchanges: unlike the individual exchange, which has a clear value proposition as the sole distribution channel for premium and cost sharing subsidies for low and moderate-income families, the value proposition for the SHOP exchange is less obvious

8 Federal Requirements Plan Management The State Insurance Agency (in most states) will work with the issuer to certify and manage the Qualified Health Plan (QHP) In order to be certified, QHP s must be accredited and offer an adequate provider network QHP s will enroll/disenroll individuals into their plans, may collect premiums, collect tax credits and cost-sharing reduction payments from the federal government, and provide federal and state reporting Possibly advantageous for state s with large Medicaid managed care programs to align the QHP offering with the Medicaid MCO offering in order to provide continuity to individuals who move in and out of coverage groups States may elect to retain control as part of the state partnership model

9 Federal Requirements Financial Management Reporting of advance premium tax credits and cost-sharing reductions Premium processing and reporting Risk adjustment includes data collection, calculation, and issuer payment transfer: Risk adjustment for QHP s ensures plans are compensated for enrolling individuals with greater health needs Risk adjustment calculation requires collection of all claims data for QHP s and analysis of the burden of risk May choose Federal risk adjustment t model or state s t may develop their own

10 Federal Requirements Consumer Assistance Education and outreach Website management Call center management Navigator management. Navigators are public or private entities or individuals that are qualified and licensed to assist consumers in navigating the eligibility and enrollment process. States may elect to retain control as part of the state partnership model

11 Functional Overview

12 Model Implementations State Versus Federal Exchange Federally-facilitated Exchange (FFE) Model All core functions of the Exchange are operated by the United States Department of Health and Human Services (HHS) on behalf of a state. t 26 states t State-based Exchange Model (SBE) All core functions of the Exchange are operated by the state. 17 states State t Partnership Exchange Model (SPE) States St t can elect to participate i t in the Federally Facilitated Exchange model but retain and operate either Plan Management or Consumer Assistance OR both Plan Management and Consumer Assistance. 7 states Consortium or Regional Exchange Model More than one state partner together to establish an exchange that serves the population of participating states.

13 Timeline High Level Exchange Timeline Exchange Goes Live January 2014 States May Change to SBE Model 1/1/16 DAY ONE Open Enrollment Begins 10/1/13 States May Move to SBE Model 1/1/15

14 State Approaches to Exchanges Catherine C Graeff, Director, Health Insurance Exchange - Cognosante

15 Status of Exchanges Today

16 What s the Future for SPE and FFE States? Some states elec+ng SPE and FFE intend to stand up SBE in January 2015, 2016 or 2017 HHS considers FFE a temporary measure Enabling legisla+on needed in many cases Expect about 15 to move to SBE for 2015 Level 1 and 2 Establishment Grants Applica+ons 4x year through 10/15/14 100% funding granted through 12/31/14 to be used for SBE establishment, SPE development, FFE integra+on efforts Ac+vi+es expanded to include start- up year expenses

17 States Have Ability to Apply for Additional Grants

18 Timeline for Wave of 2015 States Procurement June - Dec Plan Year Implementa+on Jan 2014 Oct 2014 (Open Enrollment) 5

19 Exchange Modules & Components ample

20 How will Exchange Services be Implemented? Reusability & Sustainability DDI COTS Transfer System Exchange Services and beyond 7

21 Emerging Players in Each Model DDI COTS Transfer System State Shared Exchange Service Accenture (1) CGI (3) TBD TBD CGI (1) CSC (1) Deloi[e (4) Noridian (1) Infosys (1) Maximus (1) Oracle (1) Xerox (1) Not yet announced: IL, NM Not yet procured: UT, ID MS has lost conditional approval for SBE 8

22 NESCIES Concept of States Sharing

23 Shared Exchange Service Concept

24 The Promise of Shared Services Speed to Value Ease of Adoption Lower Risk Solution Sustainable Model COTS HIX Components Pre-built Core Common Integration Reduced Customization Standards Based Single FFE off ramp for States State Specific Configuration Reusability Flexible Infrastructure Reduced Project Risk Shared development Shared services Variable PMPM costs

25 Appendix

26 SERFF System Designed by NAIC to enable issuers to send, DOI to receive, comment, approve or reject insurance industry rate and form filings SERFF HIX Plan Management Project SERFF is not intended to be the complete solu+on to Exchange Plan Management. SERFF s primary purpose is to handle func+ons related to the submission and cer+fica+on of QHPs. SERFF intends to provide integra+on with recognized accredita+on organiza+ons to make the necessary quality data available in SERFF

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