HIMSS Patient-Centered Payer Roundtable. May 16, 2013

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1 HIMSS Patient-Centered Payer Roundtable May 16, 2013

2 Agenda Welcome Topic discussion Housekeeping Call to Order and Roll Call (Gary Austin, Shelley Price) Health Insurance Marketplaces: A State Perspective (Lindy Hinman, COO, Connect for Health, CO) (Shelley Price) Adjournment 2

3 Agenda Welcome Topic discussion Housekeeping Call to Order and Roll Call (Gary Austin, Shelley Price) Health Insurance Marketplaces: A State Perspective (Lindy Hinman, COO, Connect for Health, CO) (Shelley Price) Adjournment 3

4 HIMSS Payer Roundtable Lindy Hinman Chief Operating Officer

5 What is Connect for Health Colorado An open, competitive marketplace for individuals and small employers to: Compare information regarding cost and quality Shop health plan features containing the same base benefits Determine eligibility for and access new federal financial assistance, based on income Support the health coverage decision-making process Call, chat or sit down with trained representatives for help Enroll in a health plan 5

6 Connect for Health Colorado is NOT A replacement for the current market or brokers Engaged with negotiating rates between carriers and providers Part of Medicaid A new government health care system A State agency or regulatory body An organization that pulls funding from Colorado General Fund 6

7 Exchange Value Increase competition in the marketplace through its side by side comparison shopping Provide access to federal tax credits (in the form of premium reductions) that will make health insurance more affordable Reduce uncompensated care and cost transference to the broader market Help to preserve the overall risk mix in the market - by providing affordable plans for young healthy adults Provide expanded choice for employers and employees Create transparency to allow for more informed decision-making Provide decision support, through online tools and a support network (customer service center, health coverage guides and brokers) 7

8 Individuals and Families The marketplace is for Coloradans who currently buy insurance on their own, who are uninsured, or don t have access to affordable coverage through their employer Online shopping, with assistance by phone and in-person Insurers compete for your business Health plans will provide more comprehensive coverage Customers can access new federal financial assistance to lower premiums, co-pays and deductibles Several ways to shop: browse health plans, estimate savings, or apply online for federal financial assistance 8

9 Small Employers The marketplace will provide small group plan options to Colorado employers with 2-50 employees Employers with up to 100 employees can be served in 2016 Employers can set benefit budget Employers can provide greater choice to workers Employees can use benefit allowance to shop for health plans Small business tax credits will be available (up to 50% of premium) for employers with 2-25 employees, earning on average $50,000 or less Other value-added services will be provided, like payment aggregation, management tools and ability to use brokers 9

10 Cost reduction for Individuals & Families Financial help to reduce the cost of premiums Individual earning between $15,282 to $45,960/year Couple earning between $20,628 to $62,040/year Family of four earning $31,322 to $94,200/year o Tax credit applied up-front by IRS o Tax credit is higher for Coloradans ages Financial help to reduce out of pocket costs (co-pays and deductibles) Individuals earning $15,282 to $28,725/year Family of 4 earning $31,322 to $58,875/year 10

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13 Example of Potential Reductions* Bill is a 40-year-old male making $30,000 per year Bill enters the marketplace through the website and applies for assistance paying for his coverage. Bill qualifies for $166 per month in premium reduction (tax credit). Bill shops for and compares health plans with the same base benefits. Bill finds a plan that costs $375 per month. The tax credit brings his total cost to $209 per month. * Estimate not based on actual prices 13

14 Draft Shopping Wireframe 14

15 Comprehensive Coverage Federal law requires health plans sold to individuals and small businesses inside and outside of Connect for Health Colorado to provide, at a minimum, the following categories of services, also known as essential health benefits: Ambulatory patient services Emergency Services Hospitalization Maternity/newborn care Mental health/substance abuse Prescription drugs Rehab/habilitative services and devices Laboratory services Preventive and wellness care/chronic disease management Pediatric services, including oral and vision care 15

16 Core Carrier Interactions Certification, Plan Loading, & Contracting Product Structure & Shopping Enrollments & Payments Reconciliation Customer Service 16

17 Provider Directory Plan Review in COHBE System QDP Certification QHP Certification QHP and QDP Certification, Plan Loading, &Provider Directory APR MAY JUN JUL AUG SEP OCT Rate Filing COHBE Templates Other Filings Final QHP Certification Notice (7/31) Rates Filing Binder Part 1 (5/18) Quality & Company Overview (5/31) All Other Filings Binder Part 2 (6/30) Rate Filing Other Filings Final QDP Certification Notice (7/31) COHBE Template Rates Filing Binder Part 1 (6/14) All Other Filings Binder Part 2 (6/30) Company Overview (5/31) Review PDF Designs Final PDFs Loaded (7/31) Review Plan Data Carrier Sign-Off Data Pushed to Production (8/31) Test Files Production Files Treo Kick-Off (4/19) Treo EDI Form (5/10) Test Data Submitted (6/14) Production Data Submitted (7/15) Provider Directory Live (10/1) Due to DOI Due to COHBE Due to Treo

18 Broker Certification Customer Service Testing and Connectivity Legal Agreements Legal Agreements, System Dates, and Operations Dates APR MAY JUN JUL AUG SEP OCT TPA Executed (5/10) Provide Feedback / Requested Edits for CPA Carrier Participation Agreement (CPA) Released (6/12) CPA Negotiations Complete (8/15) CPA Executed (9/15) Test Schedule Finalized (5/3) Testing COHBE EDI Form + Final WSDLs Sent to Carriers (5/10) Test Scenarios Released (5/17) Test Scenarios Finalized (6/14) Prod Connectivity Training Materials Review (TBD) CSR Train the Trainer Sessions (TBD) Send COHBE Final Hours of Op and 8XX # (8/1) Warm Transfers Begin (10/1) Broker Certification Classes Invitations to Brokers to Register (6/15) Broker Classes Begin (8/1) Brokers Certified for Open Enrollment (10/1) Due to DOI Due to COHBE Due to Treo

19 Certification, Plan Loading, & Contracting CONSIDERATIONS Delegation of Qualified Health Plan (QHP) Certification standard approvals between Exchange and Insurance Commissioner Initial certification vs. recertification Plan data loading approach and coordination with SERFF Participation agreement requirements and timing DEPENDENCIES Finalized plan management templates and AV calculator from CCIIO Insurance Commissioner timeline for regulatory approvals System access and integration with SERFF Exchange product offerings are dependent on aligning federal, state, and exchange requirements

20 Product Structure & Shopping CONSIDERATIONS Consumer choice and comparison, including supplemental coverage Flexibility for innovation and competition within the market Short and long term product strategies Decision support tools (e.g., provider directory) DEPENDENCIES Pediatric dental carve-out option Product regulation and approvals at the state and federal levels Plan data collection and management Exchanges must balance broad choices with decision support tools to assist consumers in navigating the options

21 Enrollments and Payments CONSIDERATIONS Entity responsible for premium collection Technical approach for initial enrollment, changes, and terminations Coordination of life change and grace periods implications DEPENDENCIES Federal requirement to report using a standard format (e.g., 834) Variance in carrier technology sophistication (batch vs. web service) Exchanges must define a clear solution approach and test it against diverse enrollment and eligibility scenarios

22 Reconciliation CONSIDERATIONS Core entities involved: Exchange, Carriers, and CMS System of record approach Data included in reconciliation and discrepancy resolution Expected APTC / CSR vs. Transacted APTC / CSR DEPENDENCIES Federal requirements (still being formulated) Reconciliation of this magnitude is a new process for most carriers and requires clearly defined scope and coordination

23 Customer Service CONSIDERATIONS Seamless customer service across multiple entities Rules of engagement for issue resolution and service transfers Avoiding and managing churn within the system Coordination with service centers, brokers, navigators, exchange, etc. DEPENDENCIES Varying levels of service center sophistication by carrier Information accuracy and access All market players must coordinate to create a positive, seamless customer service experience

24 Contact Website: Questions: Social (stakeholders) 24

25 Agenda Welcome Topic discussion Housekeeping Call to Order and Roll Call (Gary Austin, Shelley Price) Health Insurance Marketplaces: A State Perspective (Lindy Hinman, COO, Connect for Health, CO) (Shelley Price) Adjournment 25

26 Housekeeping HIMSS14 Call for Proposals Now through June 3: HIMSS14 Call for Reviewers Now through May 22:

27 LEVERAGING HEALTHCARE ANALYTICS TO IMPROVE ORGANIZATIONAL PERFORMANCE This 2-day event in the nation s capital will gather leading industry experts, solutions providers, key government officials and other senior healthcare professionals to help leverage analytics to improve organizational performance across the board. SESSIONS WILL COVER Data Integration and Governance Clinical and Business Analytics Data Warehousing Predictive Analytics Analytics and Healthcare Reform And Much More... KEYNOTE SPEAKER Be Like Amazon.com - Use Data & Analytics to Get Ahead of the Curve Chris Belmont System Vice President & CIO Ochsner Health System PLATINUM SPONSOR ATTENDEE PROFILE CIO, CMIO and CMO s CFO and CTO s IT Directors and Vendors Medical Directors VP, Directors and Managers for: Quality Analytics Risk Management Data Analysis Clinical Outcomes Public Health

28 Resources: Wrap-up HIMSS Calendar of Events: Webinars and Audio Conferences 28

29 Web page NEW! Wrap-up Next meeting 3 rd Thursday of the month from 4-5pm EST Thursday, June 27,

30 FY13 Leadership and Contact Information Chairperson: David Fitzgerald Enterprise Systems Architect Manager Aetna Vice Chairperson: Gary Austin Principal & Co-Founder, TranzformHealth HIMSS Staff Liaison: Shelley Price Director, Payer and Life Sciences HIMSS Nancy Devlin Sr Assoc., Payer and Life Sciences HIMSS 30

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