Small Business Health Options Program (SHOP) Policy Recommendations

Transcription

1 Small Business Health Options Program (SHOP) Policy Recommendations February 12, 2013 A service of Maryland Health Benefit Exchange

2 Rating and Defined Contribution in the Employer Choice Model Proposed rating rules from CCIIO specify that rates for all families, including those in employer groups, will be determined by aggregating the individual rate for each family member to account for factors such as age and smoking status The Board of Trustees formally adopted several SHOP recommendations on December 11, 2012, Recommendations primarily addressed the employee choice model for rating and defined contribution methodologies For the employer choice model, there was a recommendation that the average age methodology remain in place Employee choice recommendations are aligned with CCIIO proposed rating rules no issues Employer choice recommendation on average age rating needs to be revisited given proposed rating rules. 1

3 Employer Choice Rating Example with % Defined Contribution In the case where an employer picks two products from a single carrier (an HMO and a PPO), rates should be calculated for each member to determine the composite premium owed for the entire employer group. In the % contribution example, employers can still vary contribution for employee tier (e.g. single vs. family) with each employee s actual rate collected via payroll deduction based their specific information. 2

4 Employer Choice Rating Example where Employees Pay the Same Amount In the case where the employer desires that all employees pay the same amount, a composite rate is created for each designated employee tier. The employer determines the employee contribution per tier and then pays the rest. To provide additional premium contribution certainty for the employer, a reference plan can be introduced. 3

5 Employer Choice Recommendations Rating for employer-choice SHOP QHPs shall be consistent with the individual rating methodology applied to employee-choice SHOP QHPs The employer contribution options for employee choice should be applied to the employer choice model including the use of a reference plan Employers will have the ability to vary contribution % by the following dimensions: Product (HMO vs. PMO) Individual vs. Family The same minimum participation rate of 75% for the employee choice option should be applied to the employer choice option 4

6 TPA SHOP-Certification Program Update A service of Maryland Health Benefit Exchange

7 Program Opportunities Three distinct programs allow third party administrators choose how they want to participate in the SHOP Exchange Program 1: Alternate Online Marketplace: Certifies TPAs or other qualified organizations to establish an online shopping website where employees can compare and enroll into medical, dental, and vision plans per the parameters specified by the employers in conjunction with program 2 services. Program 2: SHOP Back-Office Administrative Services: Certifies TPAs to use their systems for account set-up, employer premium aggregation, billing, and collections, employer enrollment changes, and payments to carriers. Program 3: SHOP Online Administrative Services Provider Certifies TPAs to use Exchange systems to support employers and employees in both plan set-up and selection as well as back-office administrative services such as billing and collections support and managing eligibility and group roster changes. Program 3 Program 2 Program 1

8 Next Steps Program Summary Document Issued December 2012 Public Comments Received December 2012 TPA Certification Program Operational and Technical Requirements Specifications Issued on February 7, 2012 TPA Notice of Intent February 2013 TPA Certification Application Intake March 2013 (ongoing) TPA Joint Testing May 2013 (ongoing) TPA Certification July 2013 (ongoing) SHOP Operations October, 2013

9 TPA SHOP-Certification Background Slides A service of Maryland Health Benefit Exchange

10 Program Overview Who s eligible to apply? MIA Certified Third Party Administrators Companies that are not a health insurance issuer or treated as a health insurance issuer under subsection (a) or (b) of section 52 of the Code of 1986 as a member of the same controlled group of corporations (or under common control with) as a health insurance issuer Program acceptance criteria: Provides a strong business case inclusive of bringing enrollment to the SHOP and providing outstanding administrative services Deemed qualified by the MHBE to meet program business and technical requirements, including those required by HHS Agree to business agreement including performance metrics, service level agreements, and fee schedule (i.e. compensation), which will be on a PMPM basis Successfully completes all certification activities including joint testing with the MHBE Depending on TPA level of interest (via notice of intent), the MHBE may not have the bandwidth to work with all interested and qualified TPAs at the same time resulting in delaying certification for some TPAs

11 Program 1: Alternate Online Marketplace Functional Requirements Web Portal for QHP Plan Presentment Qualified Employer Information Management Defined Contribution Set-up Online Price Quoting and Premium Calculators Employee Affordability Testing Employee Plan Selection and Enrollment Performance and Metrics Reporting to the MHBE Customer Support Integrated Call Center Services Technical Requirements Compliance with Federal and State technology architecture and data security standards Secure data exchanges with the MHBE in using the data formats and transaction protocols dictated by the MHBE

12 Program 1 Service Level Requirements Technical Website availability during published service hours Data Exchange error rate Customer Service Average speed to answer % of calls answered First call resolution Enrollment Timeliness and Accuracy Timeliness of group file submissions Accuracy of group file submissions reviewing premium contribution, premium rates, group demographic information, plan effective date, and group benefits Timeliness of enrollment file submissions Accuracy of enrollment files Effectiveness of Website # of groups that complete the set-up process through to SHOP QHP purchases # of employees that start and complete the process of enrolling online All the requirements for program 2 are also included under program 1

13 Program 2: Back Office Administrative Services Functional Requirements Employer / Employee Information Intake Carrier Account Installation Ongoing Eligibility and Enrollment Management Premium Billing and Collections Carrier Payment and Financial Reconciliation Services Reporting to the MHBE Customer Support Integrated Call Center Services Technical Requirements Compliance with Federal and State technology architecture and data security standards Secure data exchanges with insurance carriers and MHBE in using the data formats and transaction protocols dictated by the MHBE

14 Program 2 Service Level Requirements Technical Website availability during published service hours (if a self-service portal is provided) Data Exchange error rate Customer Service Average speed to answer % of calls answered First call resolution Enrollment Timeliness and Accuracy Timeliness of group file submissions Accuracy of group file submissions reviewing premium contribution, premium rates, group demographic information, plan effective date, and group benefits Timeliness of enrollment file submissions Accuracy of enrollment files Eligibility Change Timeliness and Accuracy Timeliness of special enrollments and change of circumstance processing Accuracy of enrollment change file Billing Accuracy and Timeliness Timeliness of bill presentment / delivery Accuracy of billing Payment Accuracy and Timeliness Timeliness of payment to carriers Accuracy of payment to carriers

15 Program 3: SHOP Online Administrative Services Providers Functional Requirements Employer Plan Set-up Employee Roster Management Billing and Payment Support Customer Service Integrated Call Center Services Technical Requirements Limited as Program 3 participants will use MHBE SHOP systems exclusively MHBE SHOP system will provide operational and performance metrics that form the basis of compensation to Program 3 participants

16 Certification Timeline for Programs 1 and 2 Notice of Intent Application Development Certification Implementation and Operations 30 Days 30 Days Days 60 Days Two Years Application Submitted TPA Systems Development Joint Systems Testing TPA SHOP Operations Notice of Intent by TPAs MHBE App Review MHBE Decision Rendered and Business Agreement Signed MHBE Development Support MHBE Certification