Members Present. Kevin Yang (Co-Chair) Tequila Terry (Co-Chair) Ken Erdelt Sandy Walters Liddy Garcia-Bunuel Kathy Simmons.

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1 Maryland Health Benefit Exchange Implementation Advisory Committee April 18, :00 PM - 5:00 PM UMBC Tech Center 1450 S. Rolling Road Baltimore, MD Members Present Kevin Yang (Co-Chair) Tequila Terry (Co-Chair) Ken Erdelt Sandy Walters Liddy Garcia-Bunuel Kathy Simmons Tanya Robinson Vincent Ancona Louisa Tavakoli (by phone) Stephanie Scharpf (by phone) Linda Dietsch (by phone) Douglas Templeton (by phone) Members Absent Paul Kniskern Mary Lou Fox Heather Grzych Lee Diemer Lesley Wallace John Fleig Ken Hunter Dan Schauer Jeffrey Warner Julia Huggins Peter Beilenson Kevin Gavin Welcome and Introductions Kevin Yang, Chief Information Officer at the Maryland Health Benefit Exchange (MHBE), welcomed everyone to the meeting. Each member present introduced themselves. Committee Structure Discussion Mr. Yang presented a proposal to change the scope and structure of the committee s future meetings. He began by recalling the scope and purpose of the committee as it was conceived over a year previously to gain insight and advice on policy, operations, and information technology (IT) decisions from a small group of stakeholders representing the commercial carrier, Medicaid managed care organization (MCO), third-party administrator (TPA), and consumer communities. He noted that, as the date of open enrollment approaches, an increasing number of stakeholders have vital contributions to share on a range of highly technical matters. Based on these factors, Mr. Yang and the committee s Co-Chair, Tequila Terry, Director of Plan and Partner Management at MHBE, propose changing the goals and structure of the regular biweekly Implementation Advisory Committee (IAC) meetings.

2 Mr. Yang suggested that the traditional function of the IAC could be accomplished with just a portion of the regular meeting time, leaving a portion of time for more in-depth work in the style of a Joint Application Design (JAD) Session that would involve personnel and organizations that don t have a seat on the committee, but who have vital input to share. He added that those organizations that have a representative on the committee already have the regular meeting time blocked out, and that such a plan might make more efficient use of the time remaining before open enrollment begins. There was broad support by committee members for the plan. Several members noted that they wish to involve subject matter experts from their organizations in the more detailed discussions to come. Many members asked Mr. Yang to provide the topics to be discussed during the JAD-style portion of the meeting at least a week ahead of time to ensure availability of appropriate personnel. A member asked that some forthcoming JAD time be spent on Medicaid issues. Mr. Yang agreed. A member noted that there are so many detailed issues that need attention that the time set aside in Mr. Yang s proposal is not likely to be sufficient. Mr. Yang agreed, saying that additional sessions are almost certainly necessary, but that having the regular session already scheduled will help to alleviate some logistical concerns. A member suggested that the regularly scheduled meeting could be extended to later in the evening in order to accomplish more. Lena Hershkovitz, Manager of Plan Services at MHBE, added that JAD Sessions are going to be more frequent and regular, especially as the carrier integration testing period begins. She floated the idea of gathering every Thursday, rather than every other Thursday, and alternating a full JAD Session with a half-jad, half-committee meeting. SHOP Launch Timing Mr. Yang then reminded the committee of MHBE s plan to delay the start of open enrollment in the Small Business Health Options Program (SHOP) until January 1, 2014 first announced by his Co- Chair, Tequila Terry, Director of Plan and Partner Management at the previous Implementation Advisory Committee meeting on April 4, He pointed out that MHBE received feedback from carriers and from the Maryland Insurance Administration (MIA) that recommended that April 1, 2014 be the first possible effective date of coverage purchased through SHOP rather than March 1, 2014 as originally proposed. The rationale for the April 1 effective date was that carriers traditionally update rates in the small group market on a quarterly basis, which would mean that plans effective March 1, 2014 would have only a single month of rate applicability. He asked that committee members provide input on the issue. Kaiser Permanente had no preference between March 1 and April 1. Evergreen Health Cooperative advocated for March 1 they would rather see no delay whatsoever, but if a delay must be taken, Evergreen would gladly work with one-month duration of rate effectiveness. Carefirst BlueCross BlueShield preferred April 1. Delta Dental preferred April 1. Coventry Healthcare could support either date. United Healthcare couldn t give a preference and would have to check with others in the organization before responding. During the conversation, several issues were raised:

3 Carriers have the option of keeping the same plan rates for four months, from March 1, 2014 through June 30, Delaying the start of SHOP will delay the availability of tax credits to employers. Several members asked whether employers who use the SHOP when it opens can opt for a short plan year in order to have their renewal date fall on January 1, Since MHBE plans to deploy a fully functional SHOP on January 1, 2014, including employee choice, all carriers plans must be ready for shopping on that date. Mr. Yang thanked the committee for their comments and asked that any additional thoughts or input be sent to him and Ms. Terry before the end of the day on April 26, Updates from JAD Sessions Amir Drusbosky of the Noridian team gave an update on the status of development and planning for carrier implementation with a special focus on the results of the two recent JAD Sessions: April 11 and 17, He began by displaying a list of documents vital to carrier implementation along with their dates of delivery, comments, and finalization. A member noted that many dates on the slide were incorrect and asked that Mr. Drusbosky adjust them to reflect when the milestones actually occurred. Mr. Drusbosky apologized for the oversight and agreed to make the changes. Next, Mr. Drusbosky summarized the feedback from the recent JAD Sessions: error reports replacing effectuation files, standardizing the error report format, and allowing legacy TPA to carrier transactions. He explained that participants in the sessions made it clear that current practice in data exchanges between carriers and TPAs does not include effectuation files as was proposed by the Noridian team. Instead, carriers and TPAs use manual error reports, 824 files, or telephone contact to work through problems with data exchange. In response to this feedback, Mr. Drusbosky noted, MHBE will create a standardized error report format. He asked that members send examples of error reports currently in use to Ms. Hershkovitz as soon as possible to aid in the development of that standard. He also mentioned that many participants requested that they be allowed to continue using their legacy TPA-to-carrier interactions. Mr. Drusbosky and Mr. Yang then listed topics for upcoming JAD Sessions: Carrier Integration Package (CIP) TPA Integration Package (TIP) 834 Companion Guide 820 Companion Guide Broker-to-TPA-to-carrier Relationship COBRA and minimum participation in SHOP Medicaid/Medicare interaction Billing reconciliation and monthly billing cycle

4 Next, Mr. Drusbosky displayed a series of charts showing data exchanges in an array of scenarios, all updated to reflect feedback from the JAD Sessions. He noted that, in response to feedback from the JAD Sessions, effectuation files have been removed from consideration in every scenario except for when an individual consumer elects to pay his or her carrier directly, rather than through MHC. Several questions and comments surfaced in the ensuing discussion: Mr. Drusbosky noted that the charts that involve TPAs are not intended to restrict or prescribe the relationship between TPAs and carriers, since many have a long working relationship. A great deal of confusion remains around how the call centers of carriers and Program 2 TPAs are supposed to handle consumer and member inquiries, especially regarding demographic changes, coverage changes, and ID card issues. Mr. Drusbosky felt that it would be a good use of a JAD Session to run a series of such scenarios. A member asked whether an individual who enrolls in a plan on Maryland Health Connection will come away from the transaction with a physical confirmation or acknowledgement of their enrollment, perhaps in the nature of a receipt. Mr. Yang and Mr. Drusbosky replied that they would look further into the issue, but that having such a receipt available is certainly the intent. After some discussion among committee members regarding the implications of short-pays on the SHOP, Mr. Yang asked that all thoughts on the matter be held until the upcoming JAD Session dedicated to billing and payment. MHBE Billing & Payment Options Mr. Yang then asked the committee to think about and provide insight on the issue of credit card payments through Maryland Health Connection. He noted that, due to an array of new regulations, it is nearly impossible for MHBE to reliably predict the processing fee that will be levied by the State s credit card processor. MHBE has never intended to absorb that cost, nor has it intended to pass that cost on to consumers; rather, carriers have indicated willingness to absorb the processing fee. Mr. Yang asked members to respond to the proposal that MHBE take the credit card payment from consumers, pass it through to carriers in full, and then send an invoice to carriers on a monthly basis for repayment of the actual credit card processing fees incurred in the previous month. None of the committee members expressed strong objection to the plan. Some additional thoughts arose in the discussion: A member pointed out that some credit cards have higher fees than others and wondered whether the invoicing to each carrier would reflect actual costs incurred on behalf of that carrier. Mr. Yang replied that he would raise the issue with MHBE colleagues. A member asked whether, along with credit card processing fees, MHBE would invoice for other fees, and whether such fee invoicing could be consolidated to a single bill. Mr. Yang replied that he is not aware of any additional fees that MHBE will charge to carriers, but that if such fees do come into being, MHBE would be open to sensible consolidation efforts. A member asked that MHBE make it absolutely clear to consumers who choose to pay by check that their enrollment may be delayed due to the processing time required of checks. Another member cautioned that, if a consumer sends his or her initial premium payment check to a certain P.O. Box, a certain number of those consumers will attempt to send their ongoing payments to that same address.

5 General Updates and Future Topic Scheduling Ms. Hershkovitz asked members to send her their thoughts as to whether the carrier administration training scheduled for June 4, 2013 should include training on how to use the data templates created by CCIIO, noting that several carriers will already have extensive experience with those templates. Mr. Yang began to list topics for future meetings of the committee: Formulary information in the plan shopping experience Individual billing has been on the list for future topics, but the group has determined that the subject needs a JAD Session. Group contracts in employee choice Mr. Yang noted that MHBE has not as yet set a policy as to whether carriers must set up a group contract with an employee choice small business regardless of whether or not members of that group enroll with the carrier. A member asked that, before this topic is raised in a meeting, committee members be provided with scenario outlines in order to prepare. Mr. Yang agreed to do so. HSA/HRAs Mr. Kolb asked what outstanding issues remain on this topic, noting that he has meetings coming up with federal authorities at which he may be able to get some answers. o A member noted that one outstanding issue is whether or not MHBE is obliged to factor an employer s selected HSA/HRA contribution amount into the actuarial value of the health plan. o Another member noted that another outstanding issue remains around HSA/HRAs in the employee choice model wherein plans may have different deductible amounts. Pregnant Women and Medicaid Tricia Roddy of Maryland Medicaid gave the committee an update on the policy for providing Medicaid coverage to women whose income falls between 133% and 250% of federal poverty level. She reminded committee members that the Department of Health and Mental Hygiene (DHMH) and MHBE had identified two options for providing pregnant women the expanded coverage. In Option 1, eligible pregnant women would have to disenroll from their commercial health plan and enroll in Medicaid. In Option 2, eligible pregnant women would remain enrolled in their current commercial health plan but Medicaid would pay all premiums, cost sharing, and would provide wraparound services including dental care at no cost to the woman. Ms. Roddy then announced that DHMH and MHBE have decided to use Option 1. She then discussed a few reasons for the decision, mostly having to do with timing. MHBE and DHMH felt the need to put both technology and policy into place before the federal guidance on premium assistance was finalized. She noted one component of federal regulations that they did know about if any premium assistance is to be offered to eligible pregnant women, those women must be given a choice to accept that assistance and remain in their commercial health plans or to refuse the premium assistance and instead enroll in Medicaid. The technology of MHC, she explained, is not capable at this time of providing that choice it must be one or the other. With that limitation in mind, and with a significant amount of outstanding guidance on Option 2, Option 1 was chosen. Next, Ms. Roddy discussed some of the challenges around Option 1. Women must self-identify as pregnant in order to receive the expanded benefits. o This might result in a woman going all the way through her pregnancy and post partum period without accessing expanded benefits.

6 o If a woman self-identifies as pregnant during open enrollment, she will not be allowed to enroll in a commercial health plan, which presents consumer satisfaction concerns. o Outreach and communication to women will be critically important. Since commercial insurers do not do global payments, Medicaid will have to think about how to pay providers. Medicaid and MHBE will have to figure out the process of payment and enrolling newborns into Medicaid. Ms. Roddy then opened the discussion for committee members comments. Members pointed out that newborns automatically receive 30 days of coverage on the mother s health plan, whether that plan is a commercial or Medicaid MCO plan. Newborns, especially those that are not healthy, would have to be routed through MHC eligibility before those 30 days are over to ensure continuous coverage, a member pointed out, and often these situations have timeliness issues. A member asked whether MHBE and Medicaid will fix the issue preventing Option 2 from being implemented. Ms. Roddy replied that the agencies would like to continue the conversation around Option 2, but that clear federal rules would be a prerequisite. Mr. Kolb noted that another Continuity of Care Study is due to the legislature in two years which could include further study on this issue. A member asked whether an eligible pregnant woman would be able to keep her preferred OB/GYN. Ms. Roddy replied that Medicaid MCOs are required to pay the provider, but that the provider is not obligated to accept the Medicaid payment rate, so the decision lies with the OB/GYN. Another member replied that the Medicaid payment rate is expected to have increased by then to a level which is likely to be widely acceptable to providers. A member noted that outreach on this issue will be critical not only to the eligible women, but also to the provider community. Ms. Roddy agreed. A member asked what happens if a woman self-identifies as pregnant after the cutoff date for enrollment on the first of the next month. Ms. Roddy replied that that issue is still under consideration. A member asked whether the end of a pregnancy is a qualifying event that would allow a woman to enter a special enrollment period on MHC. Mr. Yang replied that it is. Ms. Roddy clarified that such women are entitled to a two-month post-partum period of coverage under Medicaid, the end of which would actually be the qualifying event. A member asked whether carriers should notify patients of their potential eligibility when they see a prenatal claim. Ms. Roddy replied that some type of communication is probably appropriate, but only on an educational level. A member cautioned that assuming that a woman wishes to remain pregnant can be a sensitive issue. Another member asked that MHBE and DHMH develop a standard for that communication. Ms. Roddy agreed to do so. Another member asked whether it would be legal for carriers to mine claims data in order to target communications based on condition. Mr. Kolb noted that the discussion seems to be heading toward conflict with the prohibition on marketing based on condition, and said he would defer to MIA and CCIIO for a ruling on the permissibility of such action. Another member noted that Medicaid MCOs currently mine their claims data as part of their disease management programs. Public Comments A member of the public asked whether pregnancy coverage is included in the essential health benefits (EHBs). The committee replied that such coverage is in EHB. The member of the public

7 then asked why women would transition to Medicaid. Ms. Roddy replied that, originally, it was thought that eligible women would lose their advance premium tax credits (APTCs) and that Medicaid requires no premium or cost sharing and provides richer benefits including dental coverage. A member of the public asked whether the MHBE Consolidated Service Center (CSC) will be part of the marketing communications collaborative, and whether CSC protocols would be covered during those meetings, or in the Implementation Advisory Committee, or in some other group. Ms. Hershkovitz cautioned that the CSC vendor has not yet been selected. Mr. Yang added that the CSC protocol discussions would likely begin in the Implementation Advisory Committee and move into JAD Sessions if necessary. A member of the committee asked whether MHBE has any communication collateral that might help explain to businesses the reasoning behind the employer defined contribution restrictions. Mr. Yang replied that he would send the materials.