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State of the State

(and Federal)

Exchanges

Dan Skari – Solution General Manager Reform Maureen O’Hara – AVP Regulatory Services

Agenda

   

The State of Exchange Implementation

  National/State view of the Exchanges TriZetto Client Experiences  CMS/Compliance variations/existing challenges

2014/2015 Operational Challenges

  Enrollment wrapping up (2014) QHP, operational and compliance items for 2015

Looking Ahead – 2015 and Beyond

  Market Trends Compliance items still to come

Conclusions/Next Steps 3

Federally Facilitated Marketplace (FFM) versus State Based Marketplaces (SBMs)

CBO 2014 Projections vs. Numbers To Date

  

8 million in exchanges

   5 million: Individual product: Subsidized 1 million: Individual product: Non-Subsidized 2 million: SHOP (Small group) 

4/15/2014:

 Over 8.2 million selected plans 83% subsidized (3/11) (CMS)

8 million new Medicaid/CHIP enrollees



2/28/2014:

8.9 million enrollees (CMS)* 

3/11/2014

– 4.4 million determined eligible by FFM

Goal: 84% of US Residents insured; uninsured: 45 million



2/2014 Gallup poll: 84.1%

of Americans insured 

1/2013

Gallup poll: 83.7% of Americans insured

*Includes both expansion, non expansion and redeterminations

SBM’s Struggling

Enrollment to Date vs. Projected Enrollment

California Colorado Connecticut DC

State

Hawaii Kentucky Maryland Massachusetts Minnesota Nevada New York Oregon Rhode Island Vermont Washington

Recent Plan Signups

1.4 million – (4/17) 124,000 – (4/14) 76,597 (4/11) 40,234 – (4/1) 8,182 – (4/16) 402,000 – (4/11) 29,500 – (4/4) 34,809 – (4/8) 50,431 – (4/27) 32,540 – (4/11) 960,000 – (4/16) 217,413 – (4/10) 27,961 – (4/8) 51,318 – (4/14) 325,000 – (4/16)

HHS Projected Enrollment March 2014

1,300,000 92,000 33,000 43,000 9,000 53,000 150,000 250,000 67,000 115,000 218,000 237,000 12,000 57,000 340,000

TriZetto Core Clients in Exchanges (for 2014)

Exchange Participation: June Not on the Exchange: 79 56% Exchange Participation: October On the Exchange: 61 44% Not on the Exchange: 87 62% On the Exchange: 53 38% Exchange Type Federal State Totals Count

21 32

53 8

Unique States

19 13

TriZetto Client Exchange/Government ‘Crossover’

Medicare/ Medicaid offering Exchange 57% Commercial only offering Exchange 24% Medicare only with Exchange - 13% Medicaid only with Exchange 6%

SHOP Exchanges

  

FFM SHOPs

 Online enrollment delayed until November 2014  Paper filing through a broker or agent until then  Premium aggregation and employee choice delayed until November 2014

SBM SHOPs

     HI, MN, NV – Clunky enrollment process due to IT CA, VT – Online enrollment delayed until fall 2014 MD – Online enrollment delayed until January 2015 ID – Online enrollment potentially delayed until summer of 2015 WA – Only 1 carrier in some counties; none in others

Nation-wide

  Fed regs create process for Tax Credit subsidies in counties where no SHOP issuer available Fed regs create process for states to do “SHOP-only” 

Will HHS actually launch a full SHOP exchange?

TriZetto Clients SHOP Participation

(For 2014) 22% 78% Exchange Type Federal State Totals 11

Count

21 32

Yes No

Count With SHOP

20 22

42 Unique States

19 13

32 Unique States With SHOP

17 11 11

2014/2015 – Operational Challenges

SHOP Exchanges – Unmet Expectations

  

2014 - Individual enrollment low initially and late engagement, SHOP even worse

 Majority of plans dealing with paper applications

For 2014, CMS is replacing the 834 enrollment reconciliation process for FF-SHOP with an Excel based process

 CMS targeting 834 reconciliation process at the start 2015

Once online enrollment for FF-SHOP is available, groups will need to sign up through the FF-SHOP.

 Direct enrollment in the FF-SHOP not available

State California Colorado Connecticut District of Columbia Kentucky Maryland Minnesota Nevada New Mexico New York Rhode Island Utah # of Businesses

850 176 65 569 13 130 117 133 350 *DC - Includes Congress & Staff

Enrollees

5,700 1,600 428 12,907* 677 <100 506 5,000 795 7,800

State Exchange Enrollment Deadlines

2014 Current Challenges

       

Enrollments effectuated – Numbers TBD Last Minute changes to enrollment deadlines Change in Circumstances – Manual

 Supporting retro-active enrollments

Multiple Enrollment Guidance Bulletins (#8)

 HICS Tickets – enrollment issues/customer support

Membership reconciliation pre-audit files Premium stabilization / MLR

 Impacts of Transitional extension

Marketplace Payment Processing Cycle

 Advance payments APTC CSR  Lack of electronic standards - Monthly spreadsheet template process – retroactivity builds by month

Edge Server Enrollment and Claims Risk Adjustment & Reinsurance

 Enrollment, Medical Claims & PBM Claims

2015 FFM Enrollment Schedule

Event

Initial FFM QHP Application Submission Window FFM Review of QHP Application Submissions as of Initial Submission Deadline Deadline for Final Submission of QHP Application Data FFM Completes Re-review of QHP Application Data; Data Locked Down Limited Data Correction Window Certification Notices and QHP Agreements Sent to Issuers, Agreements Signed, QHP Data Finalized Open Enrollment Begins Open Enrollment Closes

Date

5/27 – 6/27 6/30 – 7/25 8/7 9/22 9/24 – 10/6 10/14 – 11/3 11/15/2014 2/15/2015

2015 Challenges

  

Marketplace Quality

  

Inform Plan Certification

 Quality rating reporting Requirements

Provide Consumer Information

QHP Employee Satisfaction Surveys 

2015 Dry run – 2016 data available for

2017

benefit coverage

 Plans Contract with Hospitals with Patient Safety Evaluation Systems

2015



Monitoring of Plan Quality

 Transparency Reporting – Disenrollment information and Denied Claims  Complaints and Appeals accreditation

Minimum Essential Coverage Reporting 2015 CMS Audits 2015



Penalty Approach for 2014

 This good faith standard is set to expire at the end of 2014, and is not expected to be carried over into

2015

Challenges 2015 - 2016 State Exchange Plans

 

State Based Exchanges

 States May start a State Based Marketplace (SBM)  States may use another states SBM approach.

 States May go to HHS.gov

As states transition from FFM to SBE’s:

 Potential reconfiguration of benefits for state specific additions to EHB’s   Trading Partner Connections may require updating Payment implications  State collection of premiums  Credit card processing   Testing will be required (again) Coordination with State entity  SHOP (State may offer SHOP electronically, FFM plans to in 2015)

HHS Notice of Benefit and Payment Parameters for 2015 Final Rule

     Enrollment & Benefits

Open enrollment period for 2015

 November 15, 2014 through February 15, 2015

Cost Sharing Annual limitations

 Self-only coverage of $6,600; $13,200 for families,

Deductible Maximum limit

 Self-only coverage of $2,050; $4,100 for families 

Standalone Dental Plan

Cost sharing $350 for one child and $700 for two or more covered children 

Consumer protections

Requirements for a quality assessment and performance improvement program and discharge planning Small Business Health Options Program (SHOP)       Employee Choice in Federally-facilitated SHOPs (FF-SHOPs) Employer Choice in FF-SHOPs Premium Aggregation Services in FF SHOPs FF-SHOP may permit employers to contribute differently to the premiums of full-time and non-full-time employees When an employer elects to offer employees a choice of plans, premiums would be set using per-member rating.

A small employer in the SHOP that becomes a large employer would continue to be rated as a small employer.

ACA Third Party Payment of Qualified Health Plan Premiums



Third Party Payments

Accepting premiums and cost sharing payments from the following third-party entities on behalf of individual market QHP enrollees:   Ryan White HIV/AIDS Program; Indian tribes, tribal organizations, or urban Indian organizations; and  State and Federal Government programs.

Grounds for Civil Money Penalties

        Misconduct or non-compliance with Exchange standards and requirements applicable to issuers offering QHPs; Limiting enrollee access to medically necessary items and services required to be covered; Imposing excessive premiums; Denying or discouraging enrollment; Misrepresenting or falsifying data; Failure to remit user fees; or Failure to comply with cost-sharing reductions and APTC.

Maximum penalty imposed for each violation is

$100

for each day for each QHP issuer for each individual adversely affected

2015 & Beyond

Government is a BIG Customer and Growing



The federal government will pay for insurance for more Americans

   Tax credits are here to stay Medicaid programs will grow Lower income Americans will shift over time to government paid health care 

The federal government will regulate anything they run

  More national standardization of benefits, payments, network requirements, rates, quality measurements, etc.

Think “Medicare Advantage”

TriZetto Client Growth in Medicare

40 30 60 50 20 10 0 2007 2008

TriZetto Client Growth in Medicaid

30 25 10 5 20 15 0 2007 2008

Private Exchanges Proliferating

    

70-80% of the employers and consumers would rather purchase insurance from a private than a public exchange Plans turning to private exchanges for employer based enrollment Private Exchanges help plans offer products not subject to MLR requirements

 Ancillary product sales average 1.5x – 2x vs. traditional sales channel

Group retention/’stickiness’ is high with private exchanges – 85+% Employers reporting considerable savings on health insurance costs with private exchange option

“ The future of health care is public and private exchanges.. the place in the future where people will go to buy their health care much like they buy their airline tickets.” Mark Bertolini, CEO

TriZetto Clients' Private Exchange Decision Currently Implement ed(ing) 55% Undecided 45% 25

Employer Shift in Benefit Approach

Employers: Change in Preferred Approach to Providing Healthcare Benefits*

77%

Current Approach Next 2 – 4 years

44% 31% 7% 7% 4% 4% 8% Employer Selects Health Plan for All Employees (Employer Pays 100%) Employer Provides a Few Options for Employees to Choose (Employee Pays a % of Premium) Employer Provides Access to Private Exchange (Employer Pays Fixed Subsidy, and Employee Pays Remainder) Employees Choose a Plan on His/Her Own in Individual Market (Employer Does Not Contribute)

Confidential | Copyright *Aon Hewitt corporate healthcare exchange survey 8% 10% Other

Benefits: Differentiator to Albatross

Percentage of Employers Reporting High Confidence That Healthcare Benefits Will Be Offered at Their Organization a Decade From Now* 73% 62% 59% 57% 43% 38% 23% 25% 2003 2005 2007 2008 2009 2010 2011

Confidential | Copyright *17 th annual Towers Watson/National Business Group on Health Employer Survey 2012

Government Timeline ACA/HIPAA

Exchanges 10-1-2014 SHOP Market Open Enrollment 11-15-2014 ICD-10 10-1-2015

2013 Q4 O N D J 2014 Q1 Q2 F M A M J J Q3 Q4 A S O N D J Q1 Q2 2015 F M A M J J Q3 Q4 A S O N D J Q1 Q2 2016 F M A M J J Q3 Q4 A S O N D

Operating Rules 1-2-2014 Remittance Advise & EFT 12-31-2015 Operating Rules Certification 1 270/271. 276/277, 835 ERA EFT Q3 14 1-1-16 Claims Enrollment Premium Payments Referral

TBD Operating Rules Certification 2 Claims Enrollments Premium Payments Referrals Transaction Standards 1-2-14 Electronic Funds Transfer 1-1-14 1-1-16 Claims Attachments New HIPAA requirements and Operating Rules 28 (CAQH CORE)

6-2014 TBD 5010 ERRATA 837/835 HPID Dual Processing 11-5-12 11-7-16 Unique Health Plan Identifier Enumeration: 11/5/14 Key

Regulation Date Effective Date

Rule and/or standard

Conclusions/Next Steps

Conclusions

   

Government here to stay, with continued focus on ‘Care/’ Caid, Duals, Exchanges

 Member outreach and education important   ‘Alternate’ communication avenues extremely important Michigan Primary Care Assoc., ‘Text4Baby’  Oversight and mandate changes are constant and time intensive  SHOP, scheduled ACA changes, temporary processes etc…

Commercial lines all trending toward individual and model shifting B2B



B2C Methods of how products are marketed and purchased along with member education and retention continue to evolve

 Driving additional revenue ‘around’ ACA/MLR is crucial

Change is the only constant 30

Document

Transcript Document

State of the State

Exchanges

Dan Skari – Solution General Manager Reform Maureen O’Hara – AVP Regulatory Services

Agenda

Federally Facilitated Marketplace (FFM) versus State Based Marketplaces (SBMs)

CBO 2014 Projections vs. Numbers To Date

SBM’s Struggling

Enrollment to Date vs. Projected Enrollment

TriZetto Core Clients in Exchanges (for 2014)

TriZetto Client Exchange/Government ‘Crossover’

SHOP Exchanges

TriZetto Clients SHOP Participation

2014/2015 – Operational Challenges

SHOP Exchanges – Unmet Expectations

State Exchange Enrollment Deadlines

2014 Current Challenges

2015 FFM Enrollment Schedule

2015 Challenges

Challenges 2015 - 2016 State Exchange Plans

HHS Notice of Benefit and Payment Parameters for 2015 Final Rule

ACA Third Party Payment of Qualified Health Plan Premiums

2015 & Beyond

Government is a BIG Customer and Growing

TriZetto Client Growth in Medicare

TriZetto Client Growth in Medicaid

Private Exchanges Proliferating

Employer Shift in Benefit Approach

Benefits: Differentiator to Albatross

Government Timeline ACA/HIPAA

Conclusions/Next Steps

Conclusions

Thank You!

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