Agenda. 1. Federal Health Care Reform: Background and Overview. 2. Exchange Operations. 3. Exchange Establishment Funding

Transcription

1 Agenda 1. Federal Health Care Reform: Background and Overview 2. Exchange Operations 3. Exchange Establishment Funding

2 Federal Health Care Reform: Background and Overview

3 Affordable Care Act PPACA, Affordable Care Act, ObamaCare, federal health care reform Signed into law March 23, 2010 Medicaid Expansion Up to 138% FPL* Brief Overview of ACA Insurance Market Reforms Individual and Employer Mandates Guarantee Issue and Community Rating Essential Health Benefits (EHB) Federal premium subsidies up to 400% FPL** Health Insurance Exchanges 2014 Federal Poverty Guidelines Individual/ Family (4) *$16,104/$32,913 *$23,850/$95,400

4 Two Types of Exchanges Under ACA American Health Benefit Exchange (AHBE) Individuals and families may purchase qualified coverage through Qualified Health Plans (QHPs) Purchaser may be eligible for premium subsides based on income level Small Business Health Options Program (SHOP) Small businesses with up to 100 employees may purchase qualified coverage Premium subsidies are not available through the SHOP exchange (tax credits are available for qualified employers) States may choose to operate these as two separate exchanges or combine into a single mechanism

5 What is an Insurance Exchange? Purpose Online marketplace that enables individuals to shop, compare, and enroll in a health insurance plan Regulatory Models Active Purchaser Selective Contractor Open Marketplace Operational Models Federally Facilitated Marketplace (FFM) Healthcare.gov State-Based Marketplace (SBM) State-Federal Partnership State Partnership Model (SPM) State may choose to retain control over Plan Management and/or Consumer Assistance for both individual exchange and SHOP Bifurcated Model State has full control over SHOP while relying on the FFM for individual exchange functions. State may still retain control over Plan Management and/or Consumer Assistance for the individual exchange

6 ACA Exchange Timeline Preliminary insurance regulations take affect March 23, 2011 Deadline for HHS Secretary to begin awarding exchange grants Jan 1, 2013 HHS must determine if states have made sufficient progress in developing exchanges; will deem states as Approved, Conditionally Approved, or subject to FFE Jan 1, 2014 exchanges required to go live Jan 1, 2014 Employer and individual mandates in effect Jan 1, 2016 States permitted to enter into Health Care Choice Compacts Beginning in 2017, states may opt out of certain parts of the ACA via Section 1332 state innovation waivers July 1, 2010 Healthcare.gov goes live, simulating first Exchange Nov 16, 2012 Deadline for states to submit Exchange Blueprint to HHS for 2014 go live Jan 1, 2014 Premium tax credits available for enrollees (100%-400% FPL) Deadline for states to apply for federal grants for exchange establishment Jan 1, 2015 Exchange must be financially self-sustaining for operational costs Jan 1, 2017 States may permit large employers to use the exchange

7 Exchange Operations

8 Exchange Operations Users Individuals Small Employers Employees Brokers, Navigators, Community Partners Channels Online Phone Mail / Fax Office Business Functions Outreach & Marketing Eligibility Determination Enrollment Management Premium Billing and Collection Customer Relationship Management and Support Reporting and Performance Plan Management Employer Relations Actuarial and Risk Adjustment Program Finances State and Federal Coordination Quality Enabling Technology Portal Electronic Data Interfaces Rules Engine Calculator Document Generation /Management Reporting Systems Integration Workflow CRM

9 Exchange Business Functions Function Marketing & Outreach Eligibility Determination Enrollment Management Premium Billing and Collection Customer Relationship Management and Support Description Functionality to assist in the establishment of programs through navigators, in person assistors (IPAs), brokers and directly targeting individuals to ensure individuals, employers and plans obtain relevant information regarding the exchange, its processes and products Screening and eligibility determination for various programs, health plans and premium subsidies offered through the exchange Individuals will provide standardized information using a single streamlined application available through the exchange s multiple channels. Information will be processed by the exchange to provide premium and program eligibility results, allowing individuals to make informed enrollment decisions Process information provided by applicant as part of eligibility determination and enable applicant enrollment through the Exchange s multiple channels Present program and health plan product information in a standardized format to support objective and efficient selection process Calculation of premium subsidies based on information provided during eligibility determination process and health plan selection Collection and aggregation of payments from individuals, employers, and Federal Agencies to support timely and effective consolidated plan payments as well as sustainable Exchange financial management; Note: SBMs have the option to perform premium billing and collection for the Individual Exchange (no option for the SHOP). Implementation of a number of targeted channels to assist applicants in obtaining access to State programs and health insurance Management of multiple channels including a hot line, a website and in person locations while supporting both incoming and outgoing forms and data

10 Exchange Business Functions (cont d) Function Reporting and Performance Plan Management Employer Relations Actuarial & Risk Adjustment Program Finances State and Federal Coordination Description Gathering, consolidating and communicating data such as quality, enrollee satisfaction, encounters, fraud collected from plans and stakeholders through the Exchange, etc. to Federal Agencies Leveraging compiled information to support Exchange management functions and operations Management of certification process for all plan products and associated premiums offered through the Exchange Certification will be based on coverage transparency, the accurate and timely disclosure of claims policies and procedures; periodic financial disclosures; enrollment and disenrollment data; denied claims; rating practices; costsharing and payments with respect to out-of-network (OON) coverage; enrollee and participant rights Managing outreach, access, plan selection, enrollments, vouchers, premiums, and penalties for employers participating in the Exchange Integration with each participating employers to track application of reform mandate, report employee coverage changes; integration with Federal agencies to report employer performance and mandate implementation Manage periodic risk adjustment process through the collection of encounter data Determine and collect plan risk adjustment charges and ensure compliance to defined coverage levels Leverage financial tools to manage Exchange s financial performance and sustainability Define health plan user fee and support its collection to ensure long term financial stability of Exchange Acquisition, consolidation and transfer of individual, plan and employer data Integration of gathered data with supporting State and Federal Agencies to support performance management, enrollment management and payments

11 Marketing & Outreach How will AHIM meet its customer service business functions? Category What the Feds Call This What are some Consumer Assistance functions established by the Affordable Care Act? Details Consumer Assistance Navigator program is required Arkansas has option to establish other kinds of customer service guides and distinguish them in some way ( Marketplace Assister vs. Navigator ) Establishing a Call Center is required Insurance Department licenses navigators and other types of consumer assistance workers 11

12 Eligibility Determination and Enrollment Management How will AHIM determine a person s eligibility for premium tax credits and reduced cost sharing and/or Medicaid? How will AHIM enroll people into its health plans? Category What the Feds Call This What are some Eligibility and Enrollment functions established by the Affordable Care Act? Details Eligibility and Enrollment Ability to determine Premium Tax Credit and Reduced Cost Sharing Eligibility is required Connecting to databases that can verify information applicants submit in real time is required Coordinating eligibility functions with Medicaid to assure no customer goes through the wrong door when applying is required Providing a mechanism for individuals and families to enroll in an Exchange health plan is required 12

13 Premium Billing and Collection What mechanisms will AHIM put in place to assure health plans are paid the right amount of premiums and cost sharing subsidies on time every month Category What the Feds Call This What are some Exchange Financial Management functions established by the Affordable Care Act? Details Financial Management Monthly premium payments to health plans Determining payments to health plans for reduced cost sharing and reconciling these payments at the end of the year List billing for SHOP 13

14 Customer Relationship Management and Support What infrastructure will be put in place to interface with Arkansans who want to or have bought insurance from AHIM? Category What the Feds Call This What are some Exchange Consumer Assistance / Call Center functions established by the Affordable Care Act? Details Consumer Assistance / Call Center Navigator program is required by federal law Arkansas has option to establish other kinds of customer service guides and distinguish them in some way ( Marketplace Assister vs. Navigator ) Establishing a Call Center is required by federal law 14

15 Reporting and Performance What data will be gathered from plans and stakeholders by AHIM and transferred to Federal agencies? Category What the Feds Call This What are some Exchange Data Collection functions established by the Affordable Care Act? Details Data Collection Information on QHPs including issuer identification, state licensure requirements, network adequacy details, Essential Community Providers participation, service area, cost sharing, benefit summaries, and premium rating Quality accreditation based on 9 factors: adherence to clinical quality measures; patient experience ratings; consumer access to services; utilization management; quality assurance; provider credentialing; complaints and appeals; network adequacy and access; and patient information programs 15

16 Plan Management How will AHIM oversee its health insurance plans? Category What the Feds Call This What are some of the Plan Management functions established by the Affordable Care Act? Details Plan Management Annually certifying plans to make sure they are compliant with Affordable Care Act requirements Setting any state-specific plan requirements Rating the plans based on their quality Assuring premium rates proposed are actuarially sound and reasonable given costs 16

17 Employer Relations How will the health insurance marketplace for small businesses be organized? Category What the Feds Call This What SHOP functions are established by the Affordable Care Act Details Small Business Health Options Program (SHOP) SHOP employer and employee eligibility and enrollment Employer plan selection Employee plan selection and enrollment SHOP premium aggregation services Data on employer size for tax credit purposes Data on employer contribution levels for tax credit purposes 17

18 Actuarial & Risk Adjustment How will the acuity of different enrollees in exchange plans affect varying claims experience and be spread out amongst all exchange plans? Category What the Feds Call This What Risk Corridors, Reinsurance and Risk Adjustment functions are established by the Affordable Care Act Details Risk Corridors, Reinsurance and Risk Adjustment Risk Corridor run by the Federal government, there is no option for states to run this program. In place until December 31, Reinsurance can be run by the federal government or a state. In place until December 31, Risk Adjustments can be run by the federal government or a state. No expiration. 18

19 Program Finances How will the health insurance marketplace fund its own operations? Category What the Feds Call This What Sustainability functions are established by the Affordable Care Act Details Sustainability Exchanges must be self-sustaining in second year of operations (grant funds can be used in first year) Exchanges can generate revenue from a wide variety of sources, including (but not limited to): Administrative fee on Qualified Health Plans (QHPs) Administrative fee on consumers Advertising on website Commercial partnerships for direct marketing Industry wide fee (could include all providers in state) Industry wide fee on all health plan issuers Sell ancillary products on the Marketplace (e.g. dental, long term care, and vision) 19

20 State and Federal Coordination How will the state interact with the Federal government Category What the Feds Call This What State Reporting functions are established by the Affordable Care Act Details State Reporting Enrollment data Plan quality data 20

21 Individual Enrollment Online Medicaid Department Insurance Carrier Phone Application Process Eligibility Rules Engine Shop and Compare Enrollment Management Individuals Office Federal Data Services Hub Mail / Fax

22 SHOP Enrollment Online Insurance Carrier Phone Application Process Shop and Compare Enrollment Management Employers and Employees Office Mail / Fax

23 Third Party Vendors Category Systems Integrator (SI) Project Management Office (PMO) Independent Validation and Verification (IV&V) Call Center Navigators/Brokers Details Combines all components of the technology solution and ensures the systems function together Administers, manages, and creates a successful implementation of the Information Technology (IT) solution Validates and verifies the technology and PMO vendors through a regimented process Creates a customer service center for Exchange customers Assists individuals and/or businesses in enrolling in the Exchange 23

24 Exchange Establishment Funding

25 Federal Funding for Exchange Establishment There are two levels of Federal exchange establishment grants Level 1 Provide up to one year of funding to states that have made some progress under their exchange planning grants. States may seek additional years of Level 1 funding in order to meet the criteria necessary to apply for Level 2 funds. Remaining application due dates: 8/15/2014; 10/15/2014; 11/14/2014 Level 2 Provide up to three years of funding to states that are establishing a state-based exchange and can demonstrate capacity to establish the full set of core exchange activities. States must meet specific eligibility criteria, including legal authority to establish and operate an exchange that complies with Federal requirements available at the time of the application, governance structure for the exchange, and an initial plan discussing long-term operational costs of the exchange. States may only receive one Level 2 grant. Remaining application due dates: 8/15/2014; 10/15/2014; 11/14/2014

26 Got Questions? 26