Transcript de_plan_mgmt_naifa_051513

Presentation to the NAIFA-Delaware
May 15, 2013
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In 2012 Delaware opted to implement a State Partnership
Marketplace to serve Delaware’s individual and small group
markets.
• This decision resulted from the State’s analysis of implementation
feasibility and financial risk to the State under each available model.
•
The State Partnership Marketplace will allow the State to retain
management of both the qualified health plans offered on the
marketplace, as well as in-person consumer assistance and
outreach functions.
• These functions are the “consumer facing” areas of the marketplace
and have the greatest personal impact on Delawareans.
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In December 2012, Delaware became the first state to receive
conditional approval for State Partnership Marketplace
implementation.
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The State identified specific goals and objectives that inform the
critical decisions made regarding Marketplace-related policies,
processes and implementation approach, as well as provide a
marker for Marketplace performance measurement.
Goals:
1.
Improve access to affordable health insurance for Delawareans.
2.
Achieve financial sustainability that does not adversely impact
the Delaware insurance market (carrier selection and cost of
coverage).
3.
Assist small employers with the purchase of insurance for their
employees.
4.
Implement a model that harmonizes with the broker
community.
5.
Comply with federal regulations and guidelines for a State
Partnership Model for Plan Management and Consumer
Assistance.
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States were given some flexibility in defining their own “Partnership”
Marketplace. Under its Partnership model, Delaware will:
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Implement both Plan Management & Consumer Assistance
functions
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Conduct final eligibility determination for Medicaid/CHIP for
individuals who apply through the Federal Marketplace portal
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Defer Reinsurance program administration to federal government
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Establish a state-specific Essential Health Benefits (EHB)
benchmark
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Establish state-specific QHP certification standards in addition to
federal QHP requirements
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Retain separation between the Individual and Small Group markets
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Key Exchange functions and responsibilities retained by HHS in the
FFE State Partnership Marketplace model include:
Final certification of QHPs
Development and operations of the Marketplace Website
Eligibility determinations for premium subsidies (APTCs and CSRs)
‘Shop and Compare’ and Enrollment in QHPs
Operation of the SHOP to support small group employers/employees
Financial management, including premium aggregation, billing, audits,
etc.
Reinsurance and Risk Adjustment
Call Center Customer Support functions
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Lead State Agencies:
 Delaware Department of Health and Social Services—Lead Agency
 Delaware Insurance Department—Regulate insurance and lead operational
functions for plan management and in-person consumer assistance
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Health Care Reform Committee (HCR) – Cross-agency/program steering
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Delaware Health Care Commission–The HCC reviews and approves
committee that provides strategic and policy-level leadership, and ensures
efficient and appropriate integration among state agencies
Exchange-related policies and ensures that the Exchange aligns and
supports the state’s overall health reform goals and objectives.
In addition, Delaware continues works closely with CMS/CCIIO to
develop strategies and processes to support programmatic and
system integration within the Partnership model.
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The Marketplace Team has:
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Identified operational requirements for marketplace plan
management.
Interaction with DHSS and Federal partners and the
interagency division of responsibilities.
Established DOI divisional roles and responsibilities and
identified key marketplace personnel.
Developed business processes and standard operating
procedures (SOPs) for plan management functions.
SOPs are currently being finalized to QHP oversight and monitoring,
and in-person consumer assistance.
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Delaware is leveraging its existing operational structure and staff to
support Plan Management activities, including:
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Collect and review Issuer and plan data to support QHP certification,
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Collect and transmit necessary data to HHS
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Conduct QHP Issuer Account Management activities in coordination with HHS
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Perform QHP oversight and monitoring
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Collect additional Issuer data as required to support oversight and quality
reporting
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Verify accreditation status
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Track and resolve consumer complaints and inquiries
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Coordinate with HHS on quality rating and enrollee satisfaction survey
The DOI has hired additional, dedicated staff, and is developing
additional tools and procedures to support those PM activities that do
not easily align or naturally ‘fit’ within the current agency practices.
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The Delaware Marketplace will coordinate with a variety of
organizations and entities to educate consumers on insurance
affordability programs, and to apply for and enroll in
coverage.
Consumers will be assisted in a variety of ways:
 In person
 Online
 By telephone
Delaware Health Benefit Exchange
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Consumer Assistance Entities
Federal Navigators
Marketplace Assisters (MPAs)
Agents/Brokers/Producers
Federally-qualified Community
Centers
Federal Call Center Staff
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All assisters, with the exception of agents/brokers, are required to
provide unbiased responses to Marketplace inquiries.
◦ For example, they can explain the various components (benefits, rates, premiums,
etc.), but cannot advise on which is ‘best’ for the consumer or influence their
decision.
Delaware Health Benefit Exchange
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Agents/brokers participating in the Marketplace will
 Assist consumers in completing the eligibility application
 Compare and select QHPs
 Enroll consumers
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While producers will serve both the Individual and Small
Group markets, the state anticipates that agents and brokers
will play a critical role in helping qualified employers and
employees enroll in coverage through the Small Business
Health Options Programs (SHOP)
Delaware Health Benefit Exchange
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
QHP Certification standards require Issuers to pay the same
agent and broker compensation for enrollment through the
Marketplace/SHOP and for enrollment of similar health plans
offered outside the Marketplace/SHOP
◦ Delaware is not permitted to establish a commission schedule or
pay commissions directly to agents/brokers

The Marketplace will transmit agent/broker identifying
information (Marketplace ID and the agent’s or broker’s
national producer number-NPN) to Issuers to facilitate
payment of appropriate compensation.
Delaware Health Benefit Exchange
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Since Delaware is a Federal Partnership State, CMS will be
responsible for registering and training agent and brokers
Registration Process:
1.
2.
3.
4.
5.
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Confirm his/her identify by answering in an online form
Complete a Marketplace-specific online training course
Agree to comply with federal and state laws, rules, standards and policies,
Sign a privacy and security agreement with CMS, and
Obtain a Federally-facilitated Marketplace ID.
The DOI will continue to license and regulate producers in Delaware;
and may require state-specific training to supplement the federal
training modules.
CMS anticipates Agent/Broker registration and training to begin in
mid Summer.
Delaware Health Benefit Exchange
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As prescribed in the PPACA, all Issuers and plans participating
in the Marketplace must meet federal certification standards
for Qualified Health Plans. The Final Rule regarding federal
standards for QHPs may be found on the Federal Register at
the following URL:
https://www.federalregister.gov/articles/2012/07/20/2012-17831/patientprotection-and-affordable-care-act-data-collection-to-support-standardsrelated-to-essential
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In addition to the Federal QHP standards, Delaware chose to include some
additional standards. Highlights include:
◦ Requirements for a state-wide Rating Area and Service Area that expands provider
coverage throughout the entire state and mitigate the risk for adverse selection
◦ Network Adequacy standards that align with Medicaid and Department of Public
Health standards
◦ Issuer-required Transition Plans that support continuity of care for consumers as
they move from QHPs to Medicaid and vice-versa
◦ Quality Improvement Strategies, including a requirement that all Issuers participate,
at the prevailing rate, in the Delaware Health Information Network (DHIN)
◦ Essential Community Provider standards that include contracting with federallyqualified health centers (FQHCs) and providing reimbursement of these centers at
the appropriate rates
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The State followed a number of guidelines in developing
its QHP Standards, including:
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All plans, both inside and outside of the Marketplace, must comply
with EHB benchmarks established by the state, with certain
exceptions for stand-alone pediatric dental plans.
All state-specific QHP Certification Standards will apply to both
Individual and Small Group (SHOP) plans sold inside the Marketplace.
All QHPs must comply with existing federal standards and
regulations, including those within the ACA as well as other federal
requirements, such as Mental Health Parity.
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March 28, 2013 Application period opened for
Issuers
May 30, 2013 applications for QHPs are due
June 15, 2013 rates for QHPs are due
July 31, 2013 recommendations for certification
are due
August, 2013 1 week period for Issuers to review
what is posted on portal
September 2013 contracts signed
October 1, 2013, open enrollment begins
March 2013 open enrollment ends
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The DOI’s approach to QHP review and certification leverages
existing agency business unit reviews, federal processes and tools
that are integrated into an over-arching operational procedure.
DOI will conduct QHP certification reviews for compliance with state
and federal standards and regulations for:
Licensure and good standing
Service area
Network adequacy
Essential community providers
Marketing oversight
Accreditation
Essential health benefits standards
Actuarial value standards, including variations for cost-sharing reductions,
as well as cost-sharing limits
◦ Discriminatory benefit design
◦ Benefits for meaningful difference among similar plans, and
◦ Rates (new and increases), including compliance with rating reforms
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The
State would welcome multi-state plans to increase
competition in the Marketplace and provide Delawareans with
more choices for affordable health plans
DOI
is meeting with OPM to discuss the state’s potential
inclusion in Year 1 roll-out
OPM
has reviewed our state-specific standards and does not
anticipate any conflicts with federal guidelines.
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Embracing a culture of coordination and
collaboration among state and federal
organizations
Continually engaging the broad stakeholder
community
Ensuring that Delaware Marketplace policies and
practices support the state’s overall health care
reform goals and initiatives
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Federal resources
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www.Healthcare.gov
www.cms.marketplace.gov
http://www.dol.gov/ebsa/healthreform/
http://www.sba.gov/healthcare
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Delaware Resources
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Department of Insurance:
http://www.delawareinsurance.gov/healthreform/DEMarketplace.shtml
Delaware Health Care Commission: http://dhss.delaware.gov/dhcc/
Additional Agent and Broker federal guidance
◦ www.cciio.cms.gov/resources/regulaltions/Files/Agent-broker-51-2013
Delaware Health Benefit Exchange
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