Health Benefit Exchange Update

Kelly Smith – Director, SHOP Exchange Sherry Tomasky - Director, Stakeholder Engagement Northeast NAHU Presentation June 13, 2013

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Awarded nearly $370 million in federal funds for Exchange establishment activities

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Contracted with customer service organization

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Established and convened five Regional Advisory Committees

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Conducted background research on key policy decisions

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Invited organizations to apply to be In-Person Assistors/Navigators, created a complete broker training curriculum

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Contracted with a System Integrator to build IT system

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Invited Health Plans to participate in the Exchange Received conditional certification from HHS in December 2012

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Eligibility and Enrollment

Toll-free telephone hotline Web portal for eligibility determination and enrollment Ability to calculate the actual cost of coverage after individual tax credits and cost sharing reductions Certify individuals as exempt from individual responsibility • • • •

Certify Qualified Health Plans (QHPs)

Make available qualified health and dental plans to eligible individuals and employers Assign a quality rating and actuarial value to each QHP offered though the Exchange Require QHPs to offer Essential Health Benefits Ensure adequacy of plan networks 3

Employer Mail

SHOP End-to-End Flow and Online Experience

Broker or Agent Phone Attend DFS NY HBE Training Pass Exam Employer Online Create NY-HBE Account Identity Proofing Receive NY HBE Certification Build Company Information Agree to Terms of Participation Broker or Agent In-Person Assistor / (Broker or Navigator) Pre-Certification Training/ Application Enter Company Information Enter Company Roster Information Pre-select Plans Certification Build Companies and Rosters Select Coverage Plan(s) Send Enrollment to QHP Print and Mail Notices Resolve Problems in Customer Support Process Appeal Plan Selection Enrollment / Other Processing Customer Support Employees receive an invitation from NY HIX to log on and create an account – flow not depicted here

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Goals

Offer comprehensive affordable, coverage in all areas of the state Balance innovation with reasonable choice Make it easy for consumers to compare options Ensure health plans have adequate networks Monitor health plan quality, utilization of services, and consumer satisfaction Preserve consumer protections, as defined in federal and state law and regulation Ensure consistency with the outside market 5

• Invitation open to all licensed and certified insurers in the state in good standing and meeting state solvency requirements • Insurer may choose to participate in the Individual Exchange, the SHOP Exchange, or both • Must offer 1 Standard Plan at ever metal level, in each county of the service area • Must cover Essential Health Benefits package • Cost Sharing for Standard Plans

http://www.healthbenefitexchange.ny.gov./invitation

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Ambulatory patient services Emergency room services Hospitalization Maternity and newborn care Mental health and substance abuse disorders Prescription drugs Rehabilitation and habilitation services and devices Laboratory services Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 60%

Actuarial Values for Levels of Coverage

80% 70% Bronze Silver Gold 90% Platinum 8

• May offer up to 3 Non-Standard Plans • Cannot offer fewer benefits than Standard Plans • May offer additional benefits • Can use different networks and different cost sharing, but must be AV equivalent • Can make AV equivalent benefit substitutions for Preventative/Wellness/Chronic Disease Management or for Rehabilitation/Habilitation 9

• Invitation released January 31, 2013 • Proposals were due April 15, 2013 (every major insurer has shown interest) • Initial Provider Network Submissions were due April 30, 2013 and a second submission is due in July • Submission of Rates and Forms were due to the Dept. of Financial Services on April 30, and the QHP Binder Filings were due May 15 th • Anticipated notification of Certification is July 15, 2013. 10

Broker Training and Certification

• Exchange training will be CE credit eligible • • SHOP Training – 8 credits Individual Exchange Training – 8 credits • Timeline: • SHOP training classes begin early August and continue through 2014. • Individual Exchange training for brokers will be available in late August/September. • Certification testing immediately follows completion of training.

• Training format : Classroom, online, webinar.

• Brokers will be notified of rollout via Exchange website, email, through state associations, and on future Exchange webinars starting in July 2013.

Individual, or Authorized Representative Mail Phone Online Create NY-HX Account Create Application / Demographics Build Household / Income In-Person Assistor / (Broker or Navigator) Apply for Coverage Apply for Assistance Apply for Exemption Application / Account Management Verify at Federal Hub Verify Through NYS Interfaces Apply MAGI Rules Apply Program Specific / Special Rules Display Eligibility Results Select Coverage Plan(s) Verification Eligibility Determination Plan Selection Send Enrollment to QHP Send Enrollment to Medicaid / CHIP Print and Mail Notices Resolve Problems in Customer Support Process Appeal Enrollment / Other Processing Customer Support

Illustration of Tax Credits for Individuals

Source: Kaiser Family Foundation Subsidy Calculator

Income

Single Single Family of 4 (1 parent, 3 Children) $28,000 $40,000 $50,000

% FPL Annual Tax Credit

243% 348% 213% $2,318 $700 $2,845

Estimated Monthly Premium

$182 $317 $138 adult $27 Child Health Plus for 3 kids www.HealthBenefitExchange.ny.gov

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Online

– Through the Exchange portal for new applications and administrative renewals – Web chat for assistance

In Person

– In Person Assistors and Navigators – Agents and Brokers – Informal Assistors – Assistance available in many languages

Phone

– Leverage current public program call center – Assistance available in most languages

Mail

– Upon request 14

IPA/Navigators • Conduct community outreach/Complete Applications • Compensation from DOH grant program • 5-day training and certification required • Serve Individuals and SHOP Insurance Brokers/Agents • Complete Applications • Commission-based compensation • Training and certification required • Choose to certify in SHOP, Individual, or both Certified Application Counselors* • Conduct community outreach/Complete Applications • No compensation from Exchange • 5-day training and certification required • *Pending further federal guidance 15

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Goals

Ensure that all types of organizations permitted in federal rules are eligible to compete Provide grants to a diverse group of organizations that will provide high quality enrollment assistance, in a manner that is linguistically and culturally appropriate to the populations being served “One-Stop” consumer assistance for Exchange, Medicaid and Child Health Plus coverage Ensure availability of assistors in all counties of the State Have IPA/Navigators ready to provide assistance at open enrollment, October 1, 2013 16

Navigator RFA Issued RFA Review period Navigator RFA submission deadline WE ARE HERE Navigator awards announced Open Enrollment 17

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Contacts:

Kelly Smith Director, SHOP Exchange [email protected]

Sherry Tomasky Director, Stakeholder Engagement [email protected]

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