Health Insurance Exchange: State Choices for Health Plan Management

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1 Health Insurance Exchange: State Choices for Health Plan Management November 2012

2 Join the Conversation Share your thoughts, questions, and more on Twitter using the hashtag #ConnectureTips Every state, including those that have not defined their Essential Health Benefits (EHBs), must submit their individual Exchange Blueprint (a declaration that the state may or may not move forward with an Exchange) to the Centers for Medicare & Medicaid Services (CMS) by December 14, This deadline provides states with the necessary time to consider the available options after the Presidential Election, review potential grants, and align the appropriate legislative or gubernatorial support and action.

3 A key question that states must answer within their Exchange Blueprint is whether or not Plan Management will be operated by the state, as with the State-based Exchange (SBE) and Partnership Federally Facilitated Exchange (PFFE), or by the federal government as with the Federally Facilitated Exchange (FFE). This document provides states with an overview of Plan Management, factors to consider when deciding whether to let the federal government or the state operate Plan Management for the Exchange, and the requirements and deadlines for implementing Exchange Plan Management within a state. Introduction to Exchange Plan Management Today, state insurance regulators have authority over how the insurance industry conducts business within their respective states. Their role will not change with the advent of Exchanges regardless of whether the Exchange Plan Management function is operated by the state or the federal government. State insurance regulators will continue to review and approve the plans and rates that can be sold in a given state for plans offered both inside and outside the Exchange. Each state will designate an entity to oversee a second Qualified Health Plan (QHP) certification process for plans offered on the Exchange regardless of whether the Exchange Marketplace is operated by the federal government or the state. If the state elects to retain control over plan management they may choose to implement an SBE or a PFFE. If the state decides to let the federal government be responsible for Exchange Plan Management in their state, they will choose to implement the FFE model. Whoever the state designates to oversee Exchange Plan Management, that entity will be authorized to further regulate plans through the QHP certification process. The QHP certification process will include the following: Issuer-level Review: Licensure and good standing, network adequacy, essential community providers (ECPs), accreditation, program attestations Plan-level Review: EHBs, actuarial value standards, discriminatory benefit design meaningful difference, service area, new rates, and rate increases Although both review categories are intended to be standardized across the state and federal Exchanges, determining which method will be used to fulfill QHP compliance for each review category is the decision of the authorized Exchange Plan Management entity. For example, the entity would define the requirements needed to determine the criteria for achieving meaningful difference across QHPs offered by the same issuer to ensure that a manageable number of distinct plan options are available. By opting to run Plan Management through a PFFE or SBE model, states retain control over defining the requirements for Qualified Health Plans being sold to their residents. The Decision: Open Marketplace vs. Active Purchaser In addition to QHP Certification, the designated Exchange Plan Management entity is authorized to operate as either an open marketplace or as an active purchaser. The active purchaser model allows negotiations with insurers, determines which insurers can offer health plans through the Exchange, 3

4 and establishes criteria for participating plans. The open market model allows plans approved by the insurance regulators to be offered on the Exchange. There are both advocates and critics of each model, as well as a clear lack of national preference. Consequently, the question of authority and deciding the best model for a state s residents may be the greatest motivation for states to retain control over Exchange Plan Management. Per the guidance issued by the Center for Consumer Information and Insurance Oversight (CCIIO) on May 16, 2012 entitled General Guidance on Federally-facilitated Exchanges, at least in the first year HHS intends to certify as a QHP any health plan that meets all certification standards. In future years, HHS will analyze the QHP certification process and may identify improvements or changes to this process. In 2014, states that support the open marketplace approach may opt for either the state or federal government to operate the exchange. However, those states interested in taking a more active role in regulating the plans within the Exchange would be better served to operate the plan management function at the state level. The FFE model has not provided states with a clear indication of whether or not they will continue to operate as an open market or switch to the active purchaser model beginning in 2015 and beyond. Therefore, it is recommended that states selecting the option to let the federal government oversee their plan management functions should closely monitor the FFE decisions to allow themselves adequate reaction time to plan for future plan years if necessary. Plan Management in a PFFE Exchanges are required to be open for business in order to facilitate open enrollment in October of 2013, and those states that have not begun the process of implementing a solution will be hard pressed to establish a full SBE in time. Acting as a stepping stone for a SBE (or the end goal state of the exchange) is the opportunity for states to implement the PFFE model. A PFFE provides States with an opportunity to choose a midway point between the extremes of an FFE model and a fully State-Run Exchange. This option allows States to select the Exchange functions they believe they are able to manage, determine the level of funding and effort they are able to dedicate or obtain, and identify those functions they would prefer to have managed by the federal government. For example, an option of the state insurance regulator is to retain control over Exchange Plan Management, which supports many States in their desire to retain control over their insurance market. Retention of Exchange Plan Management functions in the SBE and PFFE models authorizes states to identify the data and other documents that are necessary to determine QHP certification and to determine what internal processes can be adapted and reused; allowing States to place a continued importance on retaining oversight with the options available to their residents. The determination as to what options are best for the State depends on where this focus and control should lie first. 4

5 Implementing Plan Management in PFFE For those states that want to retain control over the plans that can be sold through the Exchange, what those plans cost, and covered benefits, there are a number of requirements and deadlines that need to be met for the state to implement a PFFE. Each requirement is just as important as the next, and they should all be given the necessary attention in order for a state to successfully implement a PFFE within the required and allotted time frame as well as the ACA defined-requirements. Submit Blueprint: By December 14th, 2012, complete and submit the individual Exchange Blueprint indicating the intent of the state to operate Exchange Plan Management Achieve CMS Certification: In addition to the stated ACA law requirements, states will need to achieve certification from CMS. CMS must certify an Exchange before allowing that selected Exchange model to certify, display, and sell health plans. Exchanges must be certified each year for ACA compliance, as well as compliance with additional annual CMS regulations that can be tied to grant and establishment funds. State Review and Approval of Health Plans, Plans, and Rates: This process exists today and will likely continue in the same fashion as it has in the past; confirmation and documentation of this process is required. Most states will use SERFF to perform this function and its future use is anticipated for ease and continuity. Select Exchange Plan Management Tool: Exchange Plan Management is a new function and most states will be best served to implement a tool that simplifies and automates the process while offering flexibility and control over the plans offered on the Exchange. Connecture s StateAdvantage Plan Management tool provides a high level of flexibility and functionality. However, in late March 2013, states will likely have the option to leverage select functionality through the NAIC s SERFF extension for Health Insurance Exchanges as well as the FFE plan management tool. Health Plan Education & Outreach: Health plans supply the products that will be sold on the Exchange. Therefore, they must fully understand the plan upload, certification, and on-going auditing processes. Establish mutually beneficial stakeholder discussions with health plans to address their ability to form products, examine the initial pricing for premiums (as they will be capped in future Exchange plan years), and protect this information until both the health plan and Exchange sign off. QHP Data Collection: The health plan exports or uploads QHP information into the State s selected Plan Management tool in order for the QHP certification process to proceed. The Exchange will use this information to display plan benefits and calculate rates. Health plans already have a firm grasp and understanding of the function and options of the back-end plan upload process within the commercial market. How simple or complex the Exchange process becomes depends largely on the technology tool the state selects to manage the QHP Certification process. QHP Certification & Verification: The State views and approves the individual health plan QHPs. Initial communication between the state and the health plans occur until the health 5

6 plan and QHPs are approved. Any approved QHPs should be sufficiently tested and verified by the health plan (and optionally the state) to ensure that the benefits and rates display correctly. Once the QHP is offered for purchase on the Exchange, additional communication and review will be necessary to make sure that plans are available and compliant throughout the duration of the plan year. FFE Plan Synchronization: Once plans have been approved and tested at the state level, they may be uploaded onto the federal exchange for users to access, shop, compare and enroll. Ongoing Maintenance: The State should use the Plan Management tool to monitor QHP compliance as well as facilitate de-certification and renewal. Ongoing maintenance should encompass communication, tracking, and enrollment figures that help to determine process improvements and plan product changes for upcoming and future plan years for both the state and health plans. Plan Management Technology Options for States The primary components available within the Exchange Plan Management tool should include the following: Account Management, QHP certification, QHP Rate and Benefit Review, Health Plan Quality Rating, Managing Operational Data, and Compliance Monitoring. As Plan Management is a complex operation, all components are necessary for a full and comprehensive solution. Since Plan Management is a new function that resulted from the passing of ACA in March of 2010, proven and new options available to states for Plan Management continue to be limited. For states wanting to move forward now, Connecture offers the StateAdvantage Health Plan Management solution, which is currently being implemented as part of the Maryland and Minnesota Health Insurance Exchanges. StateAdvantage Health Plan Management is based on Connecture s core product that has been supporting products and rates for more than 40 health plan clients across all 50 states, including more than half of the largest health plans in the US and 47% of all Blue Cross Blue Shield plans. Connecture s StateAdvantage Health Plan Management was released in November of As an alternate option, the NAIC SERFF team is offering states an extension to their current application for form and rate filing system which will be available in late March Although the full scope of services available in SERFF will not be confirmed until March, it will likely meet the minimum ACA requirements for compliance. The FFE also offers states the option to use the Federal plan management system to carry out plan management activities. However, it is unknown at this point as to when that system will be available to states and what features and flexibility will be offered. 6

7 Conclusion With the Exchange implementation deadline nearing and many States looking to retain some authority over the Exchanges, the PFFE was provided to States for consideration by the Department of Health and Human Services (HHS) in March of As States continue to weigh their options at this late date, with the December 14th blueprint deadline quickly approaching, the idea of an effective solution should start with States picking a health plan management system. Since this is central to State operations and health plan stakeholders, and has the biggest impact on the States control of their own insurance market, this decision should be front and center for those considering any and all responses to the Exchange question (SBE, PFFE and FFE). About Connecture Connecture is the leading provider of Web-based information systems used to create health insurance marketplaces and exchanges. Its industry-proven solutions enable consumers, employers and brokers to more easily shop for, purchase and renew health insurance while minimizing back-office administrative expenses for health plans. Connecture s solutions are provided to health plans, state insurance exchanges, private exchanges and insurance brokers. More than 25 million Americans shop for their health insurance through systems built by Connecture, and more than half of the nation s 20 largest plans rely on them to sell, administer and manage their plans and products effectively. For more information, visit Wisconsin W. Corporate Dr. Suite 250 Brookfield, WI Phone: Fax: Georgia 101 Marietta Street Suite 1600 Atlanta, GA Phone: Fax: Connecticut 314 Farmington Avenue Suite 120 Farmington, CT Phone: Fax: Join the Conversation Share your thoughts, questions, and more on Twitter using the hashtag #ConnectureTips Copyright 2012 Connecture, Inc.

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