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Health Benefit Exchange Update

Kelly Smith – Director, SHOP ExchangeSherry Tomasky - Director, Stakeholder Engagement

Northeast NAHU Presentation

June 13, 2013

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

Established and convened five Regional Advisory Committees

Conducted background research on key policy decisions

Contracted with a System Integrator to build IT system

Contracted with customer service organization

Invited Health Plans to participate in the Exchange

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

Received conditional certification from HHS in December 2012

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Key Accomplishments to Date

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

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Functions of the Exchange

Certification

SHOP End-to-End Flow and Online Experience

Create NY-HBE Account

Build Company Information

Agree to Terms of

Participation

Receive NY HBE

Certification

Pre-Certification Training/ Application

Pre-select Plans

Resolve Problems in Customer Support

Select Coverage

Plan(s)

Process Appeal

Enrollment / Other Processing

Send Enrollment to

QHP

Identity Proofing

Print and Mail

Notices

Broker or Agent

Build Companies and Rosters

Enter Company

Information

Enter Company

Roster Information

Plan Selection

Attend DFS NY HBE Training

Pass Exam

Mail

Customer Support

In-Person Assistor /(Broker or Navigator)

Employer

Phone Broker or Agent

Employer

Online

Employees receive an

invitation from NY HIX to log on

and create an account – flow not depicted

here

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

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Health Plan Invitation

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Insurer Requirements

• 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

Federal Law Requires Coverage of Ten Essential Health Benefits

1. Ambulatory patient services

2. Emergency room services

3. Hospitalization

4. Maternity and newborn care

5. Mental health and substance abuse disorders

6. Prescription drugs

7. Rehabilitation and habilitation services and devices

8. Laboratory services

9. Preventive and wellness services and chronic disease management

10. Pediatric services, including oral and vision

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Bronze Silver Gold Platinum0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

60%

70%

80%

90%

Actuarial Values for Levels of Coverage

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Qualified Health Plans

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Insurer Requirements

• 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

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QHP Certification Process and Timeline

• 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 15th

• Anticipated notification of Certification is July 15, 2013.

• 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.

Broker Training and Certification

Verification

Individual EE End-to-End Flow and Online Experience

Create NY-HX

Account

Create Application /

Demographics

Build Household /

Income

Apply for Exemption

Verify at Federal Hub

Verify Through NYS

Interfaces

Application / Account Management

Display Eligibility Results

Resolve Problems in Customer Support

Select Coverage

Plan(s)

Process Appeal

Enrollment / Other Processing

Send Enrollment to

QHP

Send Enrollment to

Medicaid / CHIP

Apply for Coverage

Mail

Online

Customer Support

In-Person Assistor /(Broker or Navigator)

Apply for Assistance

Print and Mail

Notices

Individual, or Authorized

Representative

Eligibility Determination

Apply MAGI Rules

Apply Program Specific /

Special Rules

Plan Selection

Phone

Source: Kaiser Family Foundation Subsidy Calculator

Income % FPL Annual Tax Credit

Estimated Monthly Premium

Single $28,000 243% $2,318 $182

Single $40,000 348% $700 $317

Family of 4 (1 parent, 3 Children)

$50,000 213% $2,845 $138 adult$27 Child Health Plus for 3

kids

www.HealthBenefitExchange.ny.gov 13

Illustration of Tax Credits for Individuals

• 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

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Consumer Assistance and Enrollment

• Conduct community outreach/Complete Applications• Compensation from DOH grant program• 5-day training and certification required• Serve Individuals and SHOP

IPA/Navigators

• Conduct community outreach/Complete Applications• No compensation from Exchange• 5-day training and certification required• *Pending further federal guidance

Certified Application Counselors*

• Complete Applications• Commission-based compensation• Training and certification required• Choose to certify in SHOP, Individual, or both

Insurance Brokers/Agents

In-Person Assistors

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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

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IPA/Navigator RFA Released February 13, 2013

IPA/Navigator Program

Navigator RFA Issued

Navigator RFA

submission deadline

RFA Review period

Navigator awards

announced

Open Enrollment

WE ARE HERE

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Timeline

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www.HealthBenefitExchange.ny.gov

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Contacts:

Kelly SmithDirector, SHOP Exchange

KKS03@health.state.ny.us

Sherry TomaskyDirector, Stakeholder Engagement

SLT05@health.state.ny.us