Exchange Blueprint Application

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2 Exchange Blueprint Application As part of a State s Conditional Approval decision, the MHBE is required post the following sections of the Blueprint Exchange Application: Section 1.2: Exchange board and governance structure Section 2.1: Stakeholder consultation plan Section 2.3: Outreach and education plan Section 2.6: Navigators Section 2.7: Role of in-person assistance programs Section 2.8: Role of agents and brokers Section 2.9: Role of Web agents and brokers Section 3.1: State-developed single-streamlined application (if applicable) Section 3.2: Coordination strategy Section 4.4: Integration between Exchange and other State entities with respect to QHP-issuer oversight Section 8.1: Long-term operational cost plan The materials posted reflect the MHBE s position as of October 10, 2012, are draft in nature, and are subject to change as the MHBE continues to make progress across the entire spectrum of Exchange requirements.

3 Legal Authority and Governance LEGAL AUTHORITY AND GOVERNANCE STRUCTURE The legal authority for the Exchange is statutory. Legislation enacted in 2011 established the Exchange; the Maryland Health Benefit Exchange Act is codified in the Insurance Article of the Annotated Code of Maryland, Title 31. Section establishes the Exchange as a body politic and corporate, an instrumentality of the State, a public corporation and unit of State government; it states the purposes of the Exchange, and clarifies that nothing in the Act preempts or supersedes the authority of the Maryland Insurance Commissioner to regulate the insurance business in Maryland or the requirements of the Affordable Care Act (ACA). Other sections establish those provisions of the Maryland Code that apply to the Exchange (in the areas of procurement, ethics, administrative rule making, public records and public meetings, immunity and liability, and whistleblower law) and specify that the Exchange is exempt from certain provisions (taxation by State or local government, general procurement and governmental procedures not specifically applicable, general personnel provisions). ( ). Additionally, the law establishes the Board of Trustees as the governing body and specifies the composition of the Board and other relevant requirements, including quorum and voting requirements, standards and limitations pertaining to members conduct and liability, and subjects Board members to certain ethics/conflicts of interest laws; it also enumerates the powers of the Board. ( , ). The Act authorizes the Board to appoint an Executive Director, establishes the duties of the position, and provides for staffing of the Exchange. ( ). The Maryland Health Benefit Exchange Fund is established by law ( ), and the functions and operations of the Exchange are set forth in the law. ( ). During the 2012 Legislative Session, the Act was expanded significantly, but with respect to these essential enabling provisions, there were no substantive changes. Pursuant to the powers enumerated in , the Board adopted bylaws on June 3, 2011, that state with particularity the governing structure of the Board. Specifically, the bylaws delineate the duties of the Board and the Executive Director, establish Board committees and advisory committees, authorize the Executive Director to administer the Exchange Fund, set the fiscal year for the Exchange, and provide rules and procedures pertaining to Board meetings and amendments of the bylaws.

4 Annotated Code of Maryland INSURANCE TITLE 31. MARYLAND HEALTH BENEFIT EXCHANGE. Md. INSURANCE Code Ann (2012) Maryland Health Benefit Exchange established. (a) In general. -- There is a Maryland Health Benefit Exchange. (b) Nature of Exchange. -- (1) The Exchange is a body politic and corporate and is an instrumentality of the State. (2) The Exchange is a public corporation and a unit of State government. (3) The exercise by the Exchange of its authority under this title is an essential governmental function. (c) Purpose. -- The purposes of the Exchange are to:

5 (1) reduce the number of uninsured in the State; (2) facilitate the purchase and sale of qualified health plans in the individual market in the State by providing a transparent marketplace; (3) assist qualified employers in the State in facilitating the enrollment of their employees in qualified health plans in the small group market in the State and in accessing small business tax credits; (4) assist individuals in accessing public programs, premium tax credits, and cost-sharing reductions; and (5) supplement the individual and small group insurance markets outside of the Exchange. (d) Construction of powers. -- Nothing in this title, and no regulation adopted or other action taken by the Exchange under this title, may be construed to: (1) preempt or supersede: (i) the authority of the Commissioner to regulate insurance business in the State; or (ii) the requirements of the Affordable Care Act; or (2) authorize the Exchange to carry out any function not authorized by the Affordable Care Act. HISTORY: 2011, chs. 1, Applicable statutory provisions; exceptions. (a) In general. -- The Exchange is subject to: (1) the following provisions of the State Finance and Procurement Article: (i) Title 12, Subtitle 4 (Policies and Procedures for Exempt Units); and (ii) Title 14, Subtitle 3 (Minority Business Participation); (2) the following provisions of the State Government Article: (i) Title 10, Subtitle 1 (Governmental Procedures); (ii) Title 10, Subtitle 5 (Meetings);

6 (iii) Title 10, Subtitle 6, Part III (Access to Public Records); (iv) Title 12 (Immunity and Liability); and (v) Title 15 (Public Ethics); and (3) Title 5, Subtitle 3 of the State Personnel and Pensions Article. (b) Exceptions. -- The Exchange is not subject to: (1) taxation by the State or local government; (2) Division II of the State Finance and Procurement Article, except as provided in subsection (a)(1) of this section; (3) Title 10 of the State Government Article, except as provided in subsection (a)(2)(i), (ii), and (iii) of this section; or (4) Division I of the State Personnel and Pensions Article, except as provided in subsection (a)(3) of this section and elsewhere in this title. HISTORY: 2011, chs. 1, Board of Trustees. (a) Established. -- There is a Board of Trustees of the Exchange. (b) Composition. -- The Board consists of the following members: (1) the Secretary of Health and Mental Hygiene; (2) the Commissioner; (3) the Executive Director of the Maryland Health Care Commission; and (4) the following members appointed by the Governor, with the advice and consent of the Senate: (i) three members who: 1. represent the interests of employers and individual consumers of products offered by the Exchange; and 2. may have public health research expertise; and

7 (ii) three members who have demonstrated knowledge and expertise in at least two of the following areas: 1. individual health care coverage; 2. small employer-sponsored health care coverage; 3. health benefit plan administration; 4. health care finance; 5. administration of public or private health care delivery systems; 6. purchasing and facilitating enrollment in health plan coverage, including demonstrated knowledge and expertise about the role of licensed health insurance producers and third-party administrators in connecting employers and individual consumers to health plan coverage; and 7. public health and public health research, including knowledge about the health needs and health disparities among the State's diverse communities. (c) Diversity of members. -- In making appointments of members under subsection (b)(4) of this section, the Governor shall assure that: (1) the Board's composition reflects a diversity of expertise; (2) the Board's composition reflects the gender, racial, and ethnic diversity of the State; and (3) the geographic areas of the State are represented. (d) Limitations on affiliations during tenure. -- (1) For purposes of this subsection, "affiliation" means: (i) a financial interest, as defined in of the State Government Article; (ii) a position of governance, including membership on a board of directors, regardless of compensation; (iii) a relationship through which compensation, as defined in of the State Government Article, is received; or (iv) a relationship for the provision of services as a regulated lobbyist, as defined in of the State Government Article. (2) A member of the Board or of the staff of the Exchange, while serving on the Board or the

8 staff, may not have an affiliation with: (i) a carrier, an insurance producer, a third-party administrator, a managed care organization, or any other person contracting directly with the Exchange; (ii) a trade association of carriers, insurance producers, third-party administrators, or managed care organizations; or (iii) any other association of entities in a position to contract directly with the Exchange. (e) Term. -- (1) The term of a member appointed by the Governor is 4 years. (2) The terms of members appointed by the Governor are staggered as required by the terms provided for members of the Board on June 1, (3) At the end of a term, a member continues to serve until a successor is appointed and qualifies. (4) A member who is appointed after a term has begun serves only for the rest of the term and until a successor is appointed and qualifies. (f) Term limits. -- An appointed member of the Board may not serve more than two consecutive full terms. (g) Chair. -- The Governor shall designate a chair of the Board. (h) Meetings; quorum; voting. -- (1) The Board shall determine the times, places, and frequency of its meetings. (2) Five members of the Board constitute a quorum. (3) Action by the Board requires the affirmative vote of at least five members. (i) Reimbursement for expenses. -- A member of the Board is entitled to reimbursement for expenses under the Standard State Travel Regulations, as provided in the State budget. (j) Requirements. -- A member shall: (1) meet the requirements of this title, the Affordable Care Act, and all applicable State and federal laws and regulations; (2) serve the public interest of the individuals and qualified employers seeking health care

9 coverage through the Exchange; and (3) ensure the sound operation and fiscal solvency of the Exchange. (k) Standards of performance. -- A member of the Board shall perform the member's duties: (1) in good faith; (2) in the manner the member reasonably believes to be in the best interests of the Exchange; and (3) without intentional or reckless disregard of the care an ordinarily prudent person in a like position would use under similar circumstances. (l) Limitation on liability. -- A member of the Board who performs the member's duties in accordance with the standard provided in subsection (k) of this section may not be liable personally for actions taken as a member. (m) Removal. -- A member of the Board may be removed for incompetence, misconduct, or failure to perform the duties of the position. (n) State Ethics Law applicable; required disclosures. -- (1) (i) A member of the Board shall be subject to the State Ethics Law, Title 15, Subtitles 1 through 7 of the State Government Article. (ii) In addition to the disclosure required under Title 15, Subtitle 6 of the State Government Article, a member of the Board shall disclose to the Board and to the public any relationship not addressed in the required financial disclosure that the member has with a carrier, insurance producer, third-party administrator, managed care organization, or other entity in an industry involved in matters likely to come before the Board. (2) On all matters that come before the Board, the member shall: (i) adhere strictly to the conflict of interest provisions under Title 15, Subtitle 5 of the State Government Article relating to restrictions on participation, employment, and financial interests; and (ii) provide full disclosure to the Board and the public on: 1. any matter that gives rise to a potential conflict of interest; and 2. the manner in which the member will comply with the provisions of Title 15, Subtitle 5 of the State Government Article to avoid any conflict of interest or appearance of a conflict of interest.

10 HISTORY: 2011, chs. 1, Executive Director. (a) Appointment. -- (1) With the approval of the Governor, the Board shall appoint an Executive Director of the Exchange. (2) The Executive Director shall serve at the pleasure of the Board. (3) The Board shall determine the appropriate compensation for the Executive Director. (b) Duties. -- Under the direction of the Board, the Executive Director shall: (1) be the chief administrative officer of the Exchange; (2) direct, administer, and manage the operations of the Exchange; and (3) perform all duties necessary to comply with and carry out the provisions of this title, other State law and regulations, and the Affordable Care Act. (c) Staff. -- (1) The Executive Director may employ and retain a staff for the Exchange. (2) Except as provided in paragraphs (3) and (4) of this subsection, or otherwise by law, the Executive Director's appointment, retention, and removal of staff of the Exchange are not subject to Division I of the State Personnel and Pensions Article. (3) In hiring staff for functions that must be performed by State personnel under the Affordable Care Act or other applicable federal or State laws, the Executive Director's appointment, retention, and removal of staff shall be in accordance with Division I of the State Personnel and Pensions Article. (4) In hiring staff for functions that have been and currently are performed by State personnel, the Executive Director's appointment, retention, and removal of staff shall be in accordance with Division I of the State Personnel and Pensions Article. (5) Except as provided in paragraph (6) of this subsection, staff for all other positions necessary to carry out the purposes of this title shall be positions in the executive service or management service, or special appointments of the skilled service or the professional service in the State Personnel Management System.

11 (6) The Executive Director may retain as independent contractors or employees, and set compensation for, attorneys, financial consultants, and any other professionals or consultants necessary to carry out the planning, development, and operations of the Exchange and the provisions of this title. (d) Staff -- Determination of classification, grade, and compensation. -- The Executive Director shall determine the classification, grade, and compensation of staff of the Exchange hired or designated under subsection (c)(3), (4), and (5) of this section: (1) in consultation with the Secretary of Budget and Management; (2) with the approval of the Board; and (3) when possible, in accordance with the State pay plan. (e) Staff -- Changes to salary plans for State personnel. -- (1) With respect to staff of the Exchange hired or designated under subsection (c)(3), (4), and (5) of this section, the Executive Director shall submit to the Secretary of Budget and Management, at least 45 days before the effective date of the change, each change to the Exchange's salary plans that involves increases or decreases in salary ranges other than those associated with routine reclassifications and promotions or general salary increases approved by the General Assembly. (2) Reportable changes include: (i) the creation or abolition of classes; (ii) the regrading of classes from one established range to another; and (iii) the creation of new pay schedules or ranges. (3) The Secretary of Budget and Management shall: (i) review the proposed change; and (ii) at least 15 days before the effective date of the proposed change: 1. advise the Executive Director whether the change would have an adverse effect on comparable State jobs; and 2. if there would be an adverse effect, recommend an alternative change that would not have an adverse effect on comparable State jobs.

12 (4) Failure of the Secretary of Budget and Management to respond in a timely manner is deemed to be agreement with the change as submitted. (f) Staff -- Exemptions from General Fund cost savings measures. -- Except as otherwise provided in this title, an employee or independent contractor of the Exchange is not subject to any law, regulation, or executive order governing State compensation, including furloughs, pay cuts, or any other General Fund cost savings measure. HISTORY: 2011, chs. 1, Powers of Board. (a) In general. -- Subject to any limitations under this title or other applicable law, the Board shall have all powers necessary or convenient to carry out the functions authorized by the Affordable Care Act and consistent with the purposes of the Exchange. (b) Enumeration of powers not to restrict exercise of other lawful powers. -- The enumeration of specific powers in this title is not intended to restrict the Board's power to take any lawful action that the Board determines is necessary or convenient to carry out the functions authorized by the Affordable Care Act and consistent with the purposes of the Exchange. (c) Specific powers. -- In addition to the powers set forth elsewhere in this title, the Board may: (1) adopt and alter an official seal; (2) sue, be sued, plead, and be impleaded; (3) adopt bylaws, rules, and policies; (4) adopt regulations to carry out this title: (i) in accordance with Title 10, Subtitle 1 of the State Government Article; and (ii) without conflicting with or preventing application of regulations adopted by the Secretary under Title 1, Subtitle D of the Affordable Care Act; (5) maintain an office at the place designated by the Board; (6) enter into any agreements or contracts and execute the instruments necessary or convenient to manage its own affairs and carry out the purposes of this title; (7) apply for and receive grants, contracts, or other public or private funding; and (8) do all things necessary or convenient to carry out the powers granted by this title.

13 (d) Power to contract with eligible entities. -- (1) To carry out the purposes of this title or perform any of its functions under this title, the Board may contract or enter into memoranda of understanding with eligible entities, including: (i) the Maryland Medical Assistance Program; (ii) the family investment unit of the Department of Human Resources; (iii) insurance producers and third party administrators registered in the State; and (iv) any other entities that have experience in individual and small group public and private health insurance plans or facilitating enrollment in those plans. (2) The operations of the Exchange are subject to the provisions of this title whether the operations are performed directly by the Exchange or through an entity under a contract with the Exchange. (3) The Board shall ensure that any entity under a contract with the Exchange complies with the provisions of this title when performing services that are subject to this title on behalf of the Exchange. (e) Information-sharing agreements with federal and state agencies. -- (1) The Board may enter into information-sharing agreements with federal and state agencies, and other state health insurance exchanges, to carry out the provisions of this title. (2) an information-sharing agreement entered into under paragraph (1) of this subsection shall: (i) include adequate protections with respect to the confidentiality of information; and (ii) comply with all State and federal laws and regulations. (f) Procurement policies and procedures. -- (1) The Board, in accordance with Title 12, Subtitle 4 of the State Finance and Procurement Article, shall adopt written policies and procedures governing all procurements of the Exchange. (2) To the fullest extent practicable, and in a manner that does not impair the Exchange's ability to carry out the purposes of this title, the Board's procurement policies and procedures shall establish an open and transparent process that: (i) promotes public confidence in the procurements of the Exchange; (ii) ensures fair and equitable treatment of all persons and entities that participate in the

14 procurement system of the Exchange; (iii) fosters appropriate competition and provides safeguards for maintaining a procurement system of quality and integrity; (iv) promotes increased economic efficiency and responsibility on the part of the Exchange; (v) achieves the maximum benefit from the purchasing power of the Exchange; and (vi) provides clarity and simplicity in the rules and procedures governing the procurements of the Exchange. (g) Consultation with advisory committees; composition of advisory committees. -- To carry out the purposes of this title, the Board shall: (1) create and consult with advisory committees; and (2) appoint to the advisory committees representatives of: (i) insurers or health maintenance organizations offering health benefit plans in the State; (ii) nonprofit health service plans offering health benefit plans in the State; (iii) licensed health insurance producers and advisers; (iv) third-party administrators; (v) health care providers, including: 1. hospitals; 2. long-term care facilities; 3. mental health providers; 4. developmental disability providers; 5. substance abuse treatment providers; 6. Federally Qualified Health Centers; 7. physicians; 8. nurses;

15 9. experts in services and care coordination for criminal and juvenile justice populations; 10. licensed hospice providers; and 11. other health care professionals; (vi) managed care organizations; (vii) employers, including large, small, and minority-owned employers; (viii) public employee unions, including public employee union members who are caseworkers in local departments of social services with direct knowledge of information technology systems used for Medicaid eligibility determination; (ix) consumers, including individuals who: 1. reside in lower-income and racial or ethnic minority communities; 2. have chronic diseases or disabilities; or 3. belong to other hard-to-reach or special populations; (x) individuals with knowledge and expertise in advocacy for consumers described in item (ix) of this item; (xi) public health researchers and other academic experts with knowledge and background relevant to the functions and goals of the Exchange, including knowledge of the health needs and health disparities among the State's diverse communities; and (xii) any other stakeholders identified by the Exchange as having knowledge or representing interests relevant to the functions and duties of the Exchange. BYLAWS OF THE BOARD OF TRUSTEES OF THE MARYLAND HEALTH BENEFIT EXCHANGE PREAMBLE Pursuant to of the Insurance Article of the Maryland Code, the following is hereby adopted and declared as the Bylaws of the Board of Trustees of the Maryland Health Benefit Exchange. ARTICLE I CORPORATE NAME, PURPOSE, AND POWERS Section 1. The Board of Trustees (hereinafter, the Board ) is the body established by Maryland Health Benefit Exchange Act of 2011, Title 31 of the Insurance Article of the

16 Maryland Code, and charged with the responsibility for governing and managing the Maryland Health Benefit Exchange (hereinafter, the Exchange ). Section 2. The Exchange is a body corporate and politic, an instrumentality of the State, a public corporation, and an independent unit of State government. Section 3. As set forth in of the Insurance Article, the purposes of the Exchange are to: (a) Reduce the number of uninsured individuals in Maryland; (b) Facilitate the purchase and sale of qualified health plans in the individual market in Maryland by providing a transparent marketplace; (c) Assist qualified employers in Maryland in facilitating the enrollment of their employees in qualified health plans in the small group market in Maryland and in accessing small business tax credits; (d) Assist individuals in accessing public programs, premium tax credits, and cost-sharing reductions; and (e) Supplement the individual and small group insurance markets outside of the Exchange. Section 4. The Board has all the powers, rights, and privileges set forth in Title 31 of the Insurance Article; all powers necessary or convenient to carry out the functions authorized by the Affordable Care Act, 42 U.S.C et seq.; and all the powers of a Maryland corporation except where expressly limited by law. ARTICLE II OFFICERS OF THE BOARD Section 1. As set forth in of the Insurance Article, the Chair of the Board is designated by the Governor of Maryland. Section 2. The Chair is authorized to preside at the meetings of the Board, to represent the Board before all public bodies, to sign papers on behalf of the Board and/or the Exchange as authorized by the Board, and to perform such other duties as the Board may from time to time assign. Section 3. The Chair shall designate a Vice Chair, who is authorized to preside at the meetings of the Board in the absence of the Chair and to perform such other duties as the Board or the Chair may from time to time assign. ARTICLE III EXECUTIVE DIRECTOR Section 1. As set forth in of the Insurance Article, the Executive Director of the Exchange is appointed by the Board with the approval of the Governor. Section 2. The Executive Director shall:

17 (a) be the chief administrative officer of the Exchange; (b) direct, administer, and manage the operations of the Exchange; and (c) perform all duties necessary to comply with and carry out the provisions of the Maryland Health Benefit Exchange Act, other State law, and the Affordable Care Act. Section 3. The Executive Director serves at the pleasure of the Board and is entitled to the compensation established by the Board. Section 4. The Executive Director may, with the approval of the Board, and in accordance with of the Insurance Article, create or abolish positions on the staff of the Exchange. Section 5. In accordance with of the Insurance Article, the Executive Director may appoint, retain, and remove the staff of the Exchange and shall determine the classification, grade, and compensation of the staff of the Exchange. ARTICLE IV BOARD COMMITTEES Section 1. The Board may from time to time establish and define the duties of standing and temporary committees of the Board. Section 2. After consultation with the members of the Board, the Chair shall appoint the members of each standing and temporary committee established by the Board. Section 3. There is hereby established an Advisory Process Committee, which shall be a standing committee of the Board. The Advisory Process Committee shall make recommendations to the Board regarding the establishment, mission, scope of work, size and composition of the advisory committees described in (g) of the Insurance Article. In addition, the Advisory Process Committee shall, after considering the criteria set forth in (g) of the Insurance Article, recommend candidates for membership on each advisory committee. ARTICLE V ADVISORY COMMITTEES Section 1. The Board will establish, define the responsibilities of, and receive recommendations from advisory committees to assist the Exchange in carrying out its purposes. Section 2. The members of the advisory committees will be appointed by the Board. As set forth in (g) of the Insurance Article, the advisory committees shall include representatives of (i) insurers or health maintenance organizations offering benefit plans in the State; (ii) nonprofit health service plans offering health benefit plans in the State; (iii) licensed health insurance producers and advisers; (iv) third-party administrators; (v) health care

18 providers; (vi) managed care organizations; (vii) employers; (viii) public employee unions; (ix) consumers; (x) individuals with knowledge and expertise in advocacy for consumers; (xi) public health researchers and other academic experts with knowledge and background relevant to the functions and goals of the Exchange; and (xii) other stakeholders having knowledge or representing interests relevant to functions and duties of the Exchange. Section 3. Members of the Board may serve as members of advisory committees or as liaisons from the Board to the advisory committees. ARTICLE VI MARYLAND HEALTH BENEFIT EXCHANGE FUND Section 1. As set forth in of the Insurance Article, the Exchange administers the Maryland Health Benefit Exchange Fund. Section 2. The Executive Director shall have responsibility for administering the Maryland Health Benefit Exchange Fund in accordance both with Title 31 of the Insurance Article and with the policies and direction of the Board. ARTICLE VII FISCAL YEAR The fiscal year of the Exchange shall commence with the first day of July and end with the ensuing thirtieth day of June. ARTICLE VIII BOARD MEETINGS Section 1. Beginning in fiscal year 2012 commencing on July 1, 2011, the Board shall hold at least six regular meetings during each fiscal year, at such time and place as the Board may determine. Section 2. At least one of the regular meetings shall be held during the month of June and shall be designated as the annual meeting, at which time the Chair shall present, for approval by majority vote of the Board, a schedule of the time and place of regular meetings for the ensuing year. Except in an emergency, as determined by the Chair, the date of the annual meeting and other regular meetings may be changed only by majority vote of the Board. Section 3. The Executive Director shall present an annual report to the Board at the last regular meeting during each calendar year. Section 4. An agenda for the annual meeting and the other regular meetings of the Board shall be prepared by the Executive Director in accordance with the directions of the Chair and shall be sent by the Executive Director to each member of the Board at least three days in advance of each meeting. Discussions and actions by the Board shall not, however, be limited to

19 the items included on the agenda but may include any business not inconsistent with these Bylaws and within the duties and powers of the Board. Section 5. Special meetings of the Board may be called by the Chair on his or her own motion or upon written request of a majority of the Board members. The Chair shall give three days notice of any special meeting to all Board members, except where the Chair determines that special circumstances warrant shorter notice. At special meetings, only matters covered in the notice to members may be transacted. Section 6. As set forth in of the Insurance Article, five members of the Board constitute a quorum, and the Board may act only upon the affirmative vote of at least five members. Section 7. Board members may participate in any regular or annual meeting by telephone or video conferencing. Board members participating by such means shall be counted for quorum purposes, and their votes shall be counted when determining the actions of the Board. Section 8. Special meetings may be conducted by telephone or video conferencing, provided that all participating Board members deliberate collectively, each in the hearing of every other Board member and others in attendance at the meeting. The Executive Director shall designate a location where members of the public may attend any special meeting. Section 9. All Board meetings shall be conducted in accordance with the Open Meetings Act, Title 10, Subtitle 5 of the State Government Article of the Maryland Code. The Executive Director shall ensure that the schedule of all Board meetings is available to members of the public upon request. As soon as practicable after any Board meeting has been scheduled, the Executive Director shall post the time and place of the meeting on the website of the Exchange. ARTICLE IX AMENDMENTS TO THE BYLAWS These Bylaws may be amended by the affirmative vote of five members of the Board at any annual or regular meeting, provided that the proposed amendment or amendments have been sent to each member of the Board at least seven days before the meeting.

20 2.1 Stakeholder Consultation Plan A tenet of the Exchange since inception, continued stakeholder engagement provides opportunities for dialogue with diverse populations statewide leading up to open enrollment in October 2013 and beyond. The Exchange considers stakeholder consultation an essential component of the process and will continue to plan accordingly for inclusion of stakeholders, including carriers, brokers, advocates, consumers, small businesses, state agencies, and business leaders. Key activities include: u Exchange staff will continue making presentations to educate and inform individuals, small businesses, plan issuers, brokers and professionals in local and state agencies about the individual and small business exchanges The Exchange Implementation Advisory Committee (EIAC) will continue to meet throughout 2013 in order to address operational and technical issues. The EIAC was in February 2012 to engage with industry partners on key plan management, operational and technical implementation points between the Exchange and carriers, third party administrators, cooperatives and managed care organizations. The Communications Advisory Committee, a standing stakeholder committee co-chaired by the Director of the Governor s Office of Health Care Reform and the Director of Communications and Outreach for the Exchange, will continue to serve as a valuable resource for the Exchange as the outreach and communications campaign is developed and implemented. The committee comprised of academics and experienced communications practitioners, will provide feedback and recommendations on strategies and tactics relating to the outreach campaign. The Exchange is required by statute to maintain two standing advisory committees. These committees can vary from year to year but should support the decisions being made in any particular year. Three new advisory committees were established in June 2012 to provide stakeholders with the opportunity to participate in the process as the Exchange considers key policies and procedures for the implementation of the ACA; these include: Navigator Advisory Committee Plan Management Advisory Committee Continuity of Care Advisory Committee As with past committees, representatives reflect the gender, racial, ethnic and geographic diversity of the state. Each committee is comprised of members and chairs have been appointed as well as state agency liaisons. Exchange management staff has been appointed as well as a board liaison for each committee. Attached as evidence are the charters for each committee, committee rosters, meeting agendas, presentations and minutes. In addition, the Exchange is working collaboratively with the Governor s Office on Health Care Reform to facilitate two additional advisory stakeholder committees: Financing/Sustainability and Essential Health Benefits. Information for both committees is also enclosed. All committee meetings are open to the public and public comment is heard at the conclusion of each meeting in accordance with the Open Meetings Act. Public Comment forms are posted for feedback on policy decisions and all meeting schedules and materials are posted on the Exchange website. To facilitate ongoing communication with stakeholders, the Exchange maintains a website that provides information, resources and news. All meeting schedules, agendas and applicable materials are available on

21 the website for stakeholders, as well as legislation, research, Board resolutions, and pertinent information. A redesigned site is scheduled to launch in August 2012 that will provide a calendar of events, toolkits for brokers, certification manuals, navigator resources, and more.

22 2.3 Outreach and Education A market analysis and environmental scan conducted in November 2011 provided the audience segmentation and prioritization necessary to develop plans for a communications and outreach campaign in advance of open enrollment in October The Exchange continues with plans to develop a comprehensive and integrated communications and marketing campaign to educate and inform individuals and small businesses statewide about the state-based exchange beginning in late 2012 and building through the first open enrollment period in March Outreach, education and communications activities will continue throughout 2014 to further educate individuals and small businesses about circumstances and life events that impact eligibility, special enrollment periods, appeals and grievances and health literacy topics. The Exchange engaged Weber Shandwick to develop a brand identity for the online portal and provide the foundation for the advertising, public relations and outreach campaign. A complete brand identity including name, logo and style guide is expected to be complete by August Earned Media The public relations program will be developed and launched during the third quarter of 2012, serving as the catalyst for the earned media campaign to support education and outreach with various key audiences. The public relations campaign will first serve as the foundation for developing the message infrastructure for the communications campaign, providing important assets for collateral development and partnership efforts. The public relations program will include proactive media relations strategies to garner awareness for the exchange development, open enrollment, navigator training and other pertinent topics. The campaign will utilize various public relations strategies to garner media coverage, including news generation, storytelling, social media, third-party endorsements and instructional /educational editorial placements. A public relations firm will provide the Exchange with the resources and expertise necessary to reach audiences in rural, suburban and urban communities through a variety of communication channels at a level necessary to create and maintain a level of awareness, interest and motivation to achieve enrollment objectives. Paid Media A compelling paid media campaign will be developed to educate consumers and small businesses about the exchange in advance of the October 1, 2013 open enrollment period. Based on formative research, initial plans include television, radio, transit and online advertising. Print advertising may be considered for small business target in the SHOP exchange. A multi-channel social media campaign will launch in early 2013 with content and strategies designed to support enrollment objectives. Community Outreach

23 A multi-tiered community outreach program will ensure the Exchange successfully reaches populations statewide to provide important education and outreach material that is culturally and linguistically appropriate. The outreach program will focus on activities including health fairs, speaking engagements, cultural events and community events are among the myriad of opportunities. A corporate outreach program will support partnership efforts to engage the larger business community through sponsorships, inkind agreements and events such as promotions with grocery stores, pharmacies, tax preparation businesses, business trade associations and professional trade associations. Education and Training An essential component of the assistance the Exchange will provide to individuals and small businesses originates in training and education. The Exchange will develop a comprehensive training program for all assisters as well as change management training for case workers currently doing Medicaid eligibility determinations. Based on input and decisions made during the Navigator Advisory Committee, the training curriculum for navigators will be developed in the first quarter of 2013 after a training vendor is engaged. Training will also be developed and provided for all assisters statewide including producers. User Experience Design The Communications and Marketing Division will work directly with the PMO and IT vendors to ensure a seamless integration of the Exchange brand, end user experience and usability standards with the UX2014 recommendations. All content developed for the site will be tested and vetted through an editing process to ensure 508 and ACA compliance. Additionally, the Exchange is developing communications strategies through the HIX to communicate with enrollees including and text. Opportunities will be identified to integrate the advertising and social media campaign with the user experience through the HIX through storytelling, content sharing and social media.

24 2.6 Navigators Building on policy decisions initiated during the advisory committee process in 2011, the Exchange, working directly with community-based organizations, consumer advocates and brokers throughout Maryland has developed a navigator program that supplements the market, rather than replaces it. The MIA assumes a vital role as the enforcement agency for the navigator program. Due to the fact that the individual and small group markets are separate in Maryland, there will be two separate navigator programs as well. However, navigators in both the individual and SHOP Exchanges will be trained extensively on both markets in order to provide seamless handoffs. Below is a chart outlining the different programs: Individual Navigator Program Overview Responsible for outreach to uninsured individuals Navigators can present only plans inside exchange Only certified navigators can support plan selection or speak about specific impacts of APTCs Assisters can support outreach and anything leading to plan selection and/or individual subsidy discussions Certification/ Individual navigators Authorization receive certification from Exchange Navigator entities receive authorization from the Exchange Individual navigators must work for a navigator entity to be recognized SHOP Navigator Program Responsible for reaching out to uninsured groups Can present only plans inside exchange Only licensed navigators can discuss tax subsidies and support plan selection Assisters can support outreach and anything leading up to tax subsidy / plan selection discussions Must receive navigator license from MIA (different from a broker license as it is limited to the presentation of plans only inside the exchange) Enforcement MIA MIA Exchange Broker Responsible for maintaining the existing market and introducing individuals and groups to plans in the exchange as appropriate Can sell both inside and outside exchange Will be paid directly by carriers Must receive authorization from Exchange Hold an appointment by every issuer that offers a qualified plan on the SHOP or Individual Exchange.

25 Training Program Developed by Exchange Focused on subsidy, QHPs and Medicaid training Developed by MIA Focused on tax credits, QHPs and small business programs Developed by Exchange Focused on subsidies and tax credits, QHPs The Exchange has worked very closely with Medicaid and DHR to define the roles of navigators with respect to the existing case managers within the Local Health Departments (LHDs) and Departments of Social Services (DSSs). Functions within these state and local departments will remain the same and individuals may enter at any point in the system and receive the same determination. Navigators will supplement these workers to support QHP selection and enrollment. The Exchange has engaged Manatt Health Solutions to assist in the development of the Navigator program. Specially, Manatt will help Maryland answer the following questions: What specific functions Navigators should perform throughout the year How the Exchange should contract with navigator entities to balance the needs of Marylanders and the Exchange How navigators should work with Local Health Departments (LHDs) and Departments of Social Services (DSSs) How Maryland can ensure it is reaching culturally diverse and difficult to reach populations What elements should be included in navigator training to ensure: 1. All coverage options are presented equally 2. Culturally diverse populations are reached and communicated to appropriately 3. Continued education is received 4. Tax credit calculations and implications are clearly understood 5. Individuals are not harmed What conflict of interest standards should govern the Navigator program In concert with the Exchange and DHMH, Manatt will help to draft the grant application to ensure the navigator grantees perform the five duties outlined in 45 CFR The Exchange will offer grants to at least two entities, and Manatt will support Maryland in developing the navigator service level agreements in accordance with best practices. As mandated by the 2012 Exchange bill, the Navigator Advisory Committee has also been developed and will work closely with the Exchange and Manatt to help define the navigator program. Below is a summary work plan of for the Navigator Advisory Committee work: Topic Category Committee Meeting Agenda Meeting Content/ Meeting Schedule Navigator Kick Off Meeting Topics Overview of Advisory Committee roles and responsibilities. Preview topics to be Data to be Used Committee overview presentation 2011 Report to the July 18th

26 Topic Category Committee Meeting Agenda Topics addressed. Meeting Content/ Data to be Used General Assembly Meeting Schedule Discussion of past work done and decisions made on the Navigator program. Introduction of proposed Navigator Training and Certification Process regulations Maryland Exchange Bill Regulations Manatt Work Plan Slides Proposed Regulations Review Navigator RFI, Navigator Preferred Characteristics, & Options Development- Contractor/Operational Models Review consultant work plan Review of proposed Navigator Training and Certification process regulations and Producer Authorization Process Review of Draft Request for Information (RFI). Discussion on Preferred Characteristics of Navigator Model for Procurement in the Individual/SHOP Exchanges Draft Regulations MIA process regulations for producers Draft RFI Manatt Presentation on Options July 30th Navigator Regulations Discussion on Operational Models and how the Exchange should contract with Navigator entities to balance the needs of Marylanders and the Exchange. Review and discussion of draft regulations. Draft Individual Exchange Navigator Certification and Training Standards Regulations, August 6th Draft Individual Exchange Navigator Certification- Renewal, Reinstatement,

27 Topic Category Committee Meeting Agenda Topics Meeting Content/ Data to be Used Reactivation, and Termination of Certification. Meeting Schedule Options Development- Navigator Roles & Responsibilities Communcations update, RFI responses overview and Navigator roles and responsibilities discussion. Discussion of local health departments and local departments of social services. Draft Producer Authorization Regulations. Manatt Presentation on Options August 28th Discussion of Navigators and the call center. Discussion of handoffs by Navigators. Discussion of the relationship between Navigators roles and responsibilities outside the open enrollment. Discussion of Navigator performance measures. Options Development- Reaching Culturally Diverse Populations & Navigator Training Discussion on how Maryland can ensure it is reaching culturally diverse and difficult to reach populations. Manatt Presentation on Options September 20th Integration of How Options Work Together Validation of committee thinking across Navigator program models and reconsideration of how the models balance the needs of Marylanders and the Exchange. Initial review of training options

28 Topic Category Options Development- Distribution of Grants, Navigator Compensation & Oversight Committee Meeting Agenda Topics Discussion on distribution strategy for Navigator entities. Discussion on compensation for Navigators. Meeting Content/ Data to be Used Manatt Presentation of Options Meeting Schedule October 11th Discussion on oversight of Navigators. Discussion of conflicts of interest. Options Development- Navigator Training (continued) & Draft Final Report Review Discussion of SHOP. Draft Final Report Review Discussion on what elements should be included in Navigator training to ensure: 1. All coverage options are presented equally 2. Culturally diverse populations are reached and communicated to appropriately 3. Continued education is received 4. Tax credit calculations and implications are clearly understood 5. Individuals are not harmed Draft Final Report Manatt Presentation on Options October 23rd Training: The Exchange will develop a comprehensive training program for all assisters, including navigators, and existing state employees. For state employees currently doing Medicaid eligibility determinations, change management training will also be developed to incorporate an understanding of the Exchange and changes to the core eligibility system. Based on input and decisions made during the Navigator Advisory Committee, the training curriculum for navigators will be developed in the first quarter of 2013 after a training vendor is engaged. Timeline for Policy Decisions: As seen above, the Exchange is currently working to finalize several policy decisions regarding navigators. Following is the timeline through the end of the year to finalize these decisions: October 9, First introduction of policy discussion to board from Advisory Committee Chairs October 23, 2012 Detailed discussion on policy decisions. Board discussion. November 13, Exchange Board to adopt policies regarding the navigator program

29 Funding: The state budget process is currently underway in Maryland. Through this process, the Exchange will secure funding for the navigator program for fiscal year 2014 (July, 2013 June, 2014). Funding for ongoing years will be addressed through the financing plan. Please refer to section 8.1.

30 2.7 In-Person Assistance Program The Exchange intends to establish an in person assister program and is working to develop the program at this time. This program will strengthen existing efforts to reach uninsured and underserved populations through Local Health Departments (LHDs) and Departments of Social Services (DSSs) since LHDs and DSSs are traditionally viewed as a central point of contact to the uninsured in their communities. In this assister capacity, workers will help guide the uninsured to the appropriate Medicaid program or to navigators for enrollment into the Exchange. Particular attention will be paid to placing assisters in communities most in need of additional resources. To ensure that assisters do not perform certified navigator functions, LHD and LDSS employee training will be supplemented to outline the role and responsibilities of assisters in contrast to certified navigators. Training will also discuss privacy, security and conflict of interest standards. Funding for the assister program will be sought through a supplement to the Exchange s Level Two Establishment grant.

31 2.8 Agents & Brokers The state of Maryland has over 71,000 active individual producers with the health line of authority. Nearly 20,00 are actively selling on a yearly basis. Given this volume, agents and brokers are essential sales and distribution channels for most insurance carriers in the market today. Individual consumers and small business employers often work exclusively with insurance brokers to determine and address their insurance needs. Because of this, the Exchange will leverage agents and brokers for providing education on and getting individuals and small businesses enrolled into insurance plans. To achieve this, the Exchange will ensure that staff, IT systems and processes will be in place to support brokers who will be authorized to sell plans offered on the Exchange. Broker Services Program In order to effectively manage and improve the sales channel performance for the Exchange, the Broker Services Program will be designed to ensure that key functions for the engagement, authorization and monitoring of brokers occurs. Key elements of the Broker Services program include: Proactive Outreach License Verification Training Authorization Process Online Tools Service & Support Performance & Compliance Monitoring Program Feedback The Exchange will gather input on the design of the Broker Services Program through a process that allows stakeholders such as brokers and third party benefit administrators to be involved in the development stages of the program. Proactive Outreach The Broker Services department of the Exchange will be tasked with establishing and maintaining relationships with the key broker professional organizations in the state to provide regular communication and updates on the Exchange. Staff will attend broker organizational meetings and provide information on the Exchange stakeholder website to ensure brokers have timely and accurate information about Exchange activities and opportunities to collaborate. License Verification The Maryland Insurance Administration (MIA) will continue to be responsible for issuing licenses to brokers in Maryland. The Broker Services staff of the Exchange will be responsible for verifying and tracking license status of brokers. The staff will work with the MIA to obtain data on licensed insurance brokers to ensure that only individuals with current licenses are authorized to sell Exchange plans. Training Brokers will be required to complete initial training as a condition of selling plans offered through the Exchange. Training will be designed to ensure that there is a thorough understanding of Exchange policies and procedures, product information, tax credit and cost-share reduction programs, Medicaid eligibility information, available resources, and compliance requirements.

32 Authorization Process The Exchange will establish a broker authorization process that includes predetermined criteria for broker authorization and procedures for tracking brokers who are authorized to sell plans on the Exchange. 1) Authorization Criteria - The Exchange will establish minimum requirements for each broker to be authorized to sell plans. Minimum requirements could include the following: Hold a current license that qualifies them to sell health benefits in Maryland; Is in good standing with no outstanding consumer complaints; Be affiliated with all carriers participating on the Exchange; Complete Exchange required training and authorization process; Agree to privacy and security standards established by the Exchange; Work cooperatively with navigators, as applicable; Agrees to immediately report concerns or complaints of Exchange purchasers (employers, employees or individual consumers) Complete re-training education requirements; 2) Authorization Confirmation - Once brokers have been trained, authorization to sell Exchange products can be granted. Authorization confirmation will be provided to the broker by the Exchange. 3) Broker Profile Establishment - Once authorization is issued, the Broker Services department will complete the following additional steps: Issue a unique Agent/Broker Identifier Add the broker to the Exchange s authorized broker database Issue a User ID and password for secure login to online broker tools Confirm affiliation with all Exchange carriers has been validated 4) Broker Data Management The Broker Services department will ensure that minimum data regarding each broker will be captured and stored in the Exchange s broker data management system. Information that will be tracked including: Name (as appears on license, plus names used in daily activities) Agency or business name, if applicable Tax Identification Number (TIN) specific to agent or agency Business Address Phone Toll free (if applicable) Geographic areas/counties in which the agent works (some work in multiple areas of the state) Carrier affiliation documentation Agent/Broker identifier Languages spoken (fluency or proficiency) Training completion documentation Retraining documentation Consumer complaint/resolution data (specific to broker)

33 Please see the attached DRAFT regulations for Producer Authorization. These regulations were developed based on feedback from advisory committees, several state legislative committees and approved by the Insurance Commissioner and by the Exchange Board. They have been submitted to the Administrative, Executive and Legislative Review (AELR) committee for final approval. Approval is expected in December, Online Tools The Exchange will create a secure, online system with tools for brokers who will be authorized to sell plans inside the Exchange. The system will allow the broker, in a secure, password protected site, to enter details regarding an individual, family or small business, to identify available plan options, to submit census data (for small businesses), to calculate subsidy assistance/ cost-share reductions, and to identify Medicaid eligibility. The online broker system will also provide a self-service mechanism, allowing brokers to view their client listings, identify plans chosen by members, and allow them to efficiently self-audit the Exchange business they write. Broker Service & Support The Exchange Broker Services Department will provide service and support functions to authorized brokers to ensure that they receive assistance as needed to sell Exchange plans. The follow functions will be performed to ensure brokers are satisfied with their Exchange experience: 1) Sales Support- The Exchange will provide brokers with materials to assist in explaining what the Exchange is and the value proposition to individuals, families and small businesses. The Exchange will provide brokers with assistance with questions on Exchange plan comparison information and on quotes being prepared for consumers interested in Exchange plans. 2) Referral Management- The consumer portal will include functionality to allow a small business owner or individual to search for a broker who works with Exchange plans. This online directory will include agent contact information, or will allow the consumer to add their agent s unique identification number to their plan selection transaction. Additionally, Exchange Navigator and Customer service staff will have the ability to make a referral to an authorized broker when requested or if an insured small business is identified. 3) Book of Business Management The Exchange will assist brokers with managing member/group enrollment reconciliation, eligibility verification and renewal services. Additionally, the Exchange will assist brokers with small business employee enrollment meetings intended to educate employees on Exchange offerings. The Exchange will also provide support to Brokers (in conjunction with insurance carriers and third party benefit administrators) for escalated enrollment or claims issues. 4) Portal Navigation The Exchange will provide assistance to brokers with navigating the Exchange s online tools. Services such as password reset and portal performance issues will be addressed through the Broker Services department. 5) Administration The Exchange staff will perform the following key administration functions to ensure data accuracy of information in the broker management system:

34 Process broker of record changes Process transfer book of business requests Develop and manage broker polices and procedure to meet regulatory requirements Complete ad hoc reporting as needed Broker Performance & Compliance Monitoring The Exchange will establish policies and procedures to ensure performance and compliance with requirements can be measured for authorized brokers. The Exchange will develop reporting criteria to study and determine purchase patterns by broker (i.e. sales ranking reports, SHOP vs. Individual sales data, plans sold by broker/carrier). This data will be used to identify best practices, areas for improvement and assistance needed by brokers. Additionally, this information will be use to identify program compliance issues. Program Feedback In order to ensure continuous engagement and long term broker satisfaction, the Exchange will establish a Broker Advisory Committee to get input on the Broker Services Program. The Broker Advisory Committee will be charged with providing input on areas that affect broker satisfaction. The Exchange will use to committee to identify best practices and opportunities for improvement relative to the efficacy and functionality of tools provided by the Exchange, policies and procedures, and other matters relative to ongoing market conditions. The Exchange will also use the committee to identify ways to gauge broker satisfaction and improve communication. Broker Compensation The Maryland Exchange Bill of 2012 specifies that carriers will continue to compensate brokers directly for sales of insurance plans offered on the Exchange. The Exchange would facilitate this process through the HIX by allowing the broker of record to be passed on to the Insurance Carriers for the purpose of calculating commissions once a plan has been selected. To address potential consumer steering issues due differences in the inside/outside compensation model, the Exchange is considering implementing a certification requirement that carriers make commission data available on broker compensation for audit too determine if there are issues based on compensation models utilized by the carriers. Third Party Benefit Administrators As part of its Broker Services Program, the Exchange will leverage the experience of multiple full service Third Party Benefit Administrators (TPAs) operating in Maryland. The TPAs in Maryland have relationships with thousands of brokers who sell health insurance throughout the state. Brokers use the TPAs centralized online marketplaces to gain access to insurance quotes, enrollment processes, renewal processes, billing information and commission information for the individuals and small businesses they sell insurance to today. While the Exchange will provide information on qualified medical, vision and dental plans, the TPA systems offer a broader scope of services including health, life, disability, commission distribution and payroll services. Given this wider range of services, the Exchange expects that a large portion of the state s brokers will prefer to use the existing systems. In order to maximize the broker

35 distribution channel, the Exchange will give brokers the option to use the state-run Exchange portal or use the existing TPA systems. Through the state-run Exchange and through the integration of multiple TPA-enabled systems certified by Maryland, brokers will have ample access to qualified plan data. The following functions will be available for brokers in both systems: Online quoting mechanism, presentation of all available plan options Employer registration, plan design set-up, sales quote comparisons, and selection Employee registration, QHP selection, and enrollment (i.e. Shopping experience) Assist employees in finding individual coverage if employer coverage is not affordable NOTE: TPAs will be required to complete a rigorous certification process to obtain approval to display qualified plans in their systems. Section 6.0 includes details on the TPA certification process.

36 Maryland Health Benefit Exchange 3.1 Single Streamlined Application(s) for Exchange and SHOP Maryland intends to use the HHS-developed application for its single streamlined application for the Exchange and SHOP. As specified in 45 CFR , the Maryland Exchange will include a single streamlined application to determine eligibility and collect information that is necessary for enrollment in a QHP for the individual market and for Insurance Affordability Programs. A key assumption is that the HHS application will be largely compatible with recommendations from the UX 2014 effort. The reason for this caveat is that the commercial off the shelf (COTS) products procured by Maryland, most notably IBM Curam and Connecture State Advantage, are currently incorporating the UX 2014 recommendations (e.g. data elements and workflows) into their core products. Should Maryland decide that it will deviate from the HHS-developed application for any reason, the Exchange will notify CCIIO and schedule a design review meeting to present the intended changes. Maryland also intends to use the HHS-developed application for its single streamlined application for SHOP employers and employees as specified in 45 CFR Due to specific features of the Maryland small group market that were incorporated into the SHOP Exchange, Maryland may require the collection of some additional data elements such as the ability for employers to designate a certified Third Party Administrator (TPA) to support their enrollment and billing and collections activities. Additionally, Maryland intends to develop a SHOP certification program that allows TPAs to enroll employees into QHP s via their systems. As such, Maryland will publish specific application requirements (data elements, workflows, etc.) that TPAs must conform to in order to receive certification from Maryland to operate a SHOP employee enrollment function. Maryland anticipates requiring TPAs to conform to the HHS-developed SHOP application.

37 Maryland Health Benefit Exchange 3.2 Coordination strategy with Insurance Affordability Programs and the SHOP Maryland has established a state-wide Eligibility and Enrollment workgroup as part of an overall governance structure that facilitates decision making across all stakeholder agencies within the state including the Exchange, the DHMH, DHR, MIA, and DoIT. Policy decisions are identified and recommendations on technology and operations are made. Specifically, this group is charged with examining the process by which eligibility determinations are performed inclusive of what information will be provided by consumers, what information will be extracted from the Federal Data Hub, and how that information will be married up with other State eligibility sources (e.g. vital records, motor vehicle registration, and foster care) to make eligibility determinations. Through this process, the State will be able to determine if individuals meet the Modified Adjusted Gross Income (MAGI) threshold rules that qualify them for Medicaid, CHIP, advance premium tax credits, and/or cost sharing reductions. Additionally, the portal will allow consumers to specify whether they want to take the advance premium tax credit in whole or in part, if they qualify, and to receive certification from the Exchange of their eligibility status and/or exemption from the individual mandate. From a design, development, and implementation (DDI) perspective, all stakeholder State agencies are involved in joint application design (JAD) sessions and provide subject matter experts to participate on Agile Sprint teams. These SMEs are also involved in both Sprint-based testing as well as future user acceptance testing. All SMEs are tasked with evaluating whether HIX system design will work for the workers in their agencies and provide recommendations and changes to design based on their experience assisting customers on a day-to-day basis. The Exchange Project Management Office (PMO) supports coordination between stakeholder agencies and the IT systems integrator by facilitating meetings and keeping track of key questions, issues, and decisions that must be signed off by all SMEs. Maryland has identified several integration points with state agencies that will be required to share data in the context of an end-to-end eligibility and enrollment workflow. Noridian s Exact SOA platform for the core HIX will provide secure standards-based integration to external systems and data sources via its enterprise service bus (ESB). Systems that the HIX will need to integrate with include the State s legacy eligibility system, CARES, Maryland s Medicaid Management Information Systems (MMIS), the MIA s Issuer Management System (NAIC SERFF) and multiple sources of state eligibility data (e.g. vital records, motor vehicles, unemployment insurance, etc.). To the extent possible, integration with other state systems will be through modern standards-based protocols such as web services (SOAP, XML, REST, etc.) in alignment with the National Information Exchange Model (NIEM) and in accordance to the recommendations made by ONC pursuant to Section 1561 of the ACA; however, since many are older legacy systems, special application programming interfaces (API s) will be developed to access required data and work flow information. The CARES system is a key component in Maryland s programs to connect citizens to public assistance. By 2014 all MAGI-determined eligibility will move from CARES to the new HIX system; however CARES will still be employed for non-magi determinations and other social service programs such as SNAP and TANF. To avoid duplicate eligibility determinations and ensure successful integration, Maryland will need to fund development work to integrate CARES, HIX and MMIS. Below is a diagram that represents how the State will provide one point of entry for individuals, prevent duplicate eligibility determinations and limit the impact on legacy systems development.

38 As seen in the diagram, the HIX will be the single point of entry, using web capabilities to send the appropriate data to CARES for non-magi determinations and case management. Duplicate eligibility checks will be done by connecting to MMIS, which is the system of record for Medicaid services. To keep the HIX up to date on the cases managed in CARES, data feed generated at least monthly will come from CARES to the HIX. Maryland will also implement a solution to prevent duplicate notices from going out to consumers; several of the functions will be managed through a COTS solution that is integrated with the Exact platform. Maryland has identified other potential risks to case generation, reporting and interfaces in CARES that result from the HIX taking over MAGI determinations that will need to be addressed. Beyond internal state interfaces, Maryland will track evolving national standards for data exchanges (e.g. HIPAA X12), user interfaces (e.g. UX2014), development approaches, etc. by incorporating them into the overall interoperability plan with issuers, the federal government and other Exchange stakeholders. As an Early Innovator grantee, Maryland has taken a lead role in collaborating with CCIIO/OIS in planning the technical services of the Federal Data Hub and intends to be an early adopter/tester of hub functionality. Memorandums of understanding (MOUs) will be signed by the Exchange and partner agencies to authorize the exchange of eligibility verification data. Specifically, these MOU s will cover terms and condition for the following: Identification of system that requires integration with the Maryland HIX Business purpose of the data exchange Description of the interaction between the interfaced system and the HIX including method for data exchange and specific data elements that will be exchanged Timing and frequency of data exchanges Service levels and procedures for handling issues/exceptions Security and appropriate use of data (e.g. transferable? Use for other purposes?) In terms of customer assistance programs, DHMH, DHR, and the Exchange are working in concert to ensure that all Exchange assistors from navigators, brokers, and agents to case workers and eligibility specialists at local health departments and social service departments have their roles and responsibilities established with respect to state-wide eligibility and enrollment activities. Maryland intends to implement a comprehensive business change management effort that defines roles and

39 responsibilities, business services and processes, and standard operating procedures for eligibility / enrollment assistors based on their organization s function and constituent base. Additionally, the Exchange will engage a vendor to develop communications and training plans and documents that will bring the skills of assistors to requisite levels to perform their job functions. Business operations MOUs will be established between the Exchange, DHMH, and DHR as necessary to formalize these operational roles and responsibilities. As described in the materials submitted for the SHOP portion of this design review (Section 6.0), Maryland intends to follow a dual track for SHOP QHP eligibility and enrollment. Firstly, the Exchange will develop its own internal systems technology for the SHOP portal, leveraging Maryland s investment in the Individual Exchange where practical. Maryland has done preliminary business requirements analysis and determined that 76% of SHOP business requirements overlap with individual Exchange business requirements. Secondly, the Exchange will certify third party administrators (TPAs) within the state with online broker capabilities and back-office administrative functionality for enrollment management, billing, and collection to perform SHOP functions within the state in the service of their small employer customers. Business agreements with those TPAs will be established as part of the SHOP certification process. Additional information on state-wide collaboration and governance Ensuring a seamless and coordinated approach from planning through implementation has been a focal point for Maryland s leadership team since the ACA was enacted in Throughout the process, the goal has been to establish permanent structures to foster program integration, as well as cultivate a shared vision of information technology implementation. Within the past six months specifically, significant progress has been made as a multi-agency team has sought to identify and define coordinated business workflows. The structure of the HCRCC laid the early foundation for close program integration to ensure seamless eligibility and enrollment processes among State health and human service programs, and coordination on issues related to the regulation of insurance companies. In Maryland, Medicaid and the Children s Health Insurance Program (MCHIP) are both housed within DHMH. The Secretaries of DHMH and DHR, as well as the Exchange Executive Director and the Commissioner of MIA are all HCRCC members. The structure to support these partnerships is reinforced through the Exchange Board, whose members include the Secretary of DHMH and the Maryland Insurance Commissioner, as well as the Executive Director of the MHCC. In particular, the inclusion of the Secretary of DHMH and Insurance Commissioner as members of both the HCRCC and Exchange Board facilitates communication with MIA on many issues relevant to the Exchange, such as the financial stability and solvency of health insurers, certification of plans, premium rate and form review, state licensure of health insurers and producers, and compliance with applicable federal and state laws in health insurers and producers business practices. The Secretaries of DHMH and DHR, as well as the Executive Director of the Exchange, personally have created an environment of intensive collaboration, with all three entities the departments working together in tandem to develop a policy strategy as well as the systems and operational infrastructure necessary to achieve a no wrong door approach to eligibility and enrollment. A weekly meeting is attended by the principals of all three organizations, as well as their key staff members, chaired by the leadership partnership to review the implementation progress of the enrollment and eligibility system. A governance structure has been established that incorporates all three agencies with representation at every decision level. In addition, the Exchange and Medicaid are uniquely tied in Maryland, given that

40 Medicaid is housed within DHMH. Furthermore, Secretary Joshua M. Sharfstein, M.D, co-chairs the HCRCC and serves as chair of the Exchange Board. The Exchange has moved forward with detailing the specific functions required to operate the Exchange, and has included state entities currently performing particular functions into planning the operations to meet future requirements. For example, the MIA currently reviews health plan rates and benefits. These detailed lists have served as a starting point for discussions with the MIA, DHMH, and MHCC for final decisions on the allocation of responsibilities through Please see the Proposal to Meet Requirements for more details on this process.

41 4.4 Ensure Ongoing Issuer Compliance The Exchange will implement a staffing model to ensure dedicated resources and workflows are in place to perform issuer oversight and monitor issuer performance and compliance. Furthermore, in certain areas the Exchange will collaborate with other state agencies to ensure there is integration with respect to issuer oversight and compliance. As part of its compliance monitoring program, the Exchange will ensure that medical, dental and vision issuers comply with policies and laws associated with: o Plan certification, recertification and decertification o State insurance market requirements o State network adequacy standards o Rate increase approval and justification process o Enrollee complaint resolution o Plan quality o Collection of race, ethnicity, language, interpreter use and cultural competency Plan Certification, Recertification and Decertification The Exchange will collaborate with the Maryland Insurance Administration (MIA) to ensure issuers and plans meet requirements of the Affordable Care Act. During plan certification, the MIA will review the following submitted information to ensure the ACA required benefit design standards are met: Essential Health Benefits included Limitations on cost sharing met Actuarial value/metal level requirements met Discriminatory benefit design not identified On an annual basis, the Exchange will review the performance of participating health, dental and vision plan issuers and make recommendations on areas of improvement for the following areas: Enrollment information Network adequacy Quality information Complaints/Grievances On a biennial basis, a formal recertification process will occur that requires the Exchange to review all of the original certification data of participating health, dental and vision plan issuers to confirm the plan still meets requirements and can be offered to consumers. Additionally, the Exchange will work with the MIA to ensure that plan issuers are in good standing in order to offer qualified plans on the Exchange. Sanctions that are unresolved within the timeframe dictated by the MIA and Exchange could be grounds for decertification. State Insurance Market Requirements The Exchange will collaborate with the Maryland Insurance Administration to ensure issuers are meeting the market requirements established in state law. The following market requirements will be monitored. Issuers must obtain prior approval of premium rate and contract language from the Maryland Insurance Administration Issuers must provide at least a bronze level of coverage

42 Issuers must offer at least one qualified plan at the silver level and one qualified plan at the gold level in the individual market outside the Exchange if the issuer participates in the Exchange s individual market Issuers must offer at least one qualified health plan at the silver level and one qualified plan at the gold level in the small group market outside the SHOP Exchange if the issuer participates in the SHOP Exchange Issuers must charge the same premium rate for each qualified health plan regardless of whether the qualified health plan is offered through the Exchange, through a producer outside the Exchange or directly from the issuer Issuers must offer catastrophic plans inside and outside of the Exchange if catastrophic plans are offered Issuers must not charge any cancellation fees or penalties Issuers must ensure that cost-sharing requirements of do not exceed limits Issuers must ensure that deductibles do not exceed the limit Issuers must offer a child-only plan to individuals under age 21 that is rated for child-only coverage Issuers may offer dental and vision benefits as stand-alone plans, as an endorsement to a medical plan, and sold in conjunction with a medical plan Compliance with Network Adequacy Standards On a quarterly basis, the Exchange Plan Management staff will utilize network adequacy software procured by the Exchange to monitor issuer networks, compare networks across issuers, and report on accessibility of providers to the Exchange population. Rate Increase Approval and Justification Process The Exchange will require that plan issuers follow the existing market requirement to file rate changes with the Maryland Insurance Administration along with a rate change justification that will be made available to the public. Enrollee Complaint Resolution Maryland has a strong and demonstrated legacy of providing support to consumers for handling complaints and grievances about health care and consumer protections. Existing call centers and resource lines in the state through Medicaid, DHR, MIA and the OAG assist consumers by responding to requests for information, answering questions, facilitating health plan enrollment and/or provider selection, filing complaints and handling grievances and appeals. The Health Education and Advocacy Unit (HEAU) in the Consumer Protection Division of the Office of the Attorney General (OAG) assists consumers with health care-related complaints as well as the internal appeals and grievance process when coverage has been denied by a carrier. The Exchange is working with these state agencies to develop the process for tracking and resolving Exchange enrollee complaints. Quality The Exchange will collaborate with the Maryland Health Care Commission (MHCC) to obtain information on health plan quality and performance. The Consumer Assessment of Health Providers and Systems (CAHPS) from the Agency for Healthcare Research and Quality (AHRQ) and Healthcare Effectiveness Data and Information Set (HEDIS) from the NCQA will be used to both assist consumers in their purchase decisions and also provide insight to the Exchange on the quality performance of the plan.

43 Collection of Race, Ethnicity, Language, Interpreter Use and Cultural Competency (RELICC) Data The Exchange will require issuers to use the evalu8 tool from the National Business Coalition on Health. This tool will allow the Exchange to collect data on race, ethnicity, language, interpreter use and cultural competence data. By having this information available, the Exchange anticipates being able to monitor whether or not issuers are serving culturally diverse populations appropriately. It will also enable Maryland to identify and address health care disparities in future years.

44 8.1 Long Term Operating Cost, Budget and Management Plan In order to meet the statutory requirement to be self-sustaining by January, 2015, the Maryland Health Benefit Exchange, working closely with legislatively-appointed committees and other interested stakeholders, continues to evaluate and assess a number of potential revenue models to meet the selfsustainability requirement. During the fall of 2011, the Exchange contracted Wakely Consulting Group (Wakely) to assist the Financing and Sustainability Advisory Committee in determining a financing strategy. Wakely provided analytical and consultative support to the Committee, which was tasked with giving input to the Exchange Board of Directors on the subject of Exchange financing. As a result of this engagement, the Board recommended to the Maryland General Assembly that the Exchange consider an approach that blended two primary sources of revenue; (1) a transaction-based assessment, generally tied to enrollment; and (2) a broad-based assessment or public source of financing, such as a portion of state tax revenues. In addition, in the spring of 2012 the Maryland Health Benefit Exchange Act of 2012 was signed into law, which created a joint legislative-executive committee (Joint Committee) tasked with making recommendations regarding Exchange self-sustainability to the Governor and the General Assembly by December 1, Different from the 2011 work, this study requires detailed understanding of the operating costs for the Exchange beginning in 2015, as well as detailed estimates of the financial impact of specific options. In the summer of 2012 Wakely was hired to provide a thorough and detailed financial selfsustainability analysis to the Joint Committee to assist with these recommendations. The Exchange has undertaken a thorough approach in evaluating potential revenue models, including soliciting public stakeholder input, which will ensure that the Exchange will be prepared for self-sustainability. Following is an excerpt from the analysis evaluating the funding mechanism options: Value of the Exchange The Exchange will serve a broad range of markets and populations, and has both a business value and a public value. One aspect of the Exchange s operations includes narrowly focused activities that directly benefit its issuer partners, such as the marketing of health plans, the determination of individual eligibility for federal tax credits and cost sharing subsidies, and the required monthly reconciliation and reporting of federal tax credits. Another aspect involves elements that more broadly benefit the entire health care marketplace, such as the development of a web portal that simplifies the comparison of carriers and plan designs, along with the provision of subsidizes to make insurance more affordable. To evaluate potential revenue models, the Exchange must first identify the markets, populations, and entities that derive value from the Exchange and specifically determine how these groups will benefit from Exchange operations. The three main market segments the Exchange will serve have been categorized as (I) Issuers of QHPs and Medicaid, (II) the Health Care Industry, (III) the Public and State. Figure 1: Three Segments of Exchange Value

45 The Exchange will provide a broad range of services and value to each of these three segments, as identified below: Figure 2: Values Provided by the Exchange I. Issuers of QHPs & Medicaid II. Health Care Industry III. Public and State Eligibility Determination & Enrollment Account Installation & Management Marketing & Outreach Customer Service New Membership opportunity previously uninsured Premium Aggregation for Small Business Increased Insurance Premium and Provider Revenue Reduction in Hospital Charity Care Reduced Provider Bad Debt Supporting use of innovative product designs and payment methodologies Expanded access to health insurance coverage A form of Uninsurance Insurance Reduction in number of uninsured in Maryland Enhance coverage in minimum health insurance benefits Trustworthy source of health care reform information Eligibility and mandate appeals administration Exchange Revenue Model Options To further assess and analyze the alignment of a revenue source with the specific value provided by the Exchange, the following seven criteria were applied to a number of potential revenue models to evaluate their relative suitability: 1. Exchange Value Relationship,