state to state exchange on health insurance exchanges

State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010

State to State Exchange on Health Insurance Exchanges

Supported by the Health Resources and Services Administration

Monday, November 22, 2010 This event will begin at 1:30pm Eastern

Please hold until Anne Gauthier starts the conferenceThe audio portion of this web event can be accessed by dialing

800-269-3762


Agenda1:30-1:35pm Welcome

Anne Gauthier, Senior Fellow, NASHP

1:35-1:50pm Overview of Key Exchange Design IssuesSonya Schwartz, Program Director, NASHP

1:50-2:35pm Interview About Current Exchange ThinkingTrish Riley, Director, Maine Governor’s Office of Health Policy and Finance

Jane Cline, Commissioner, West Virginia Office of Insurance2:35-2:55pm Question and Answer with Audience

2:55-3:00pm Wrap Up


Overview of Key Design Issues

Sonya SchwartzProgram Director, NASHP


Design Issue #1: Overall Vision

• Sub-state, state, regional, or federal option?

• One exchange or two (one for small business, one for individuals) ?

• Allow all plans to participate or select plans that meet certain standards?


Design Issue #2: Governance

• New or existing stateexecutive branch agency under the Governor?

• Quasi public entity governed by a Board?

• State-established non-profit?


Design Issue #3: Eligibility and Enrollment Systems

• One system or interface that links separate systems?

• Who will develop it and where will it sit?

• How does it link to Medicaid, CHIP and other programs?

• How do states develop the information technology resources?


Design Issue #4: Tools to Achieve Affordability

• Exchange as market organizer or active purchaser?

• Rewarding or encouraging high value plans or delivery system reforms?

• Use tools to prevent adverse selection?


Design Issue #5: Stakeholder Engagement

• Use the governing entity as a tool for involving stakeholders?

• Hold public hearings on major decisions?

• Opportunities for public comment on proposals?

• Feedback loop?


Today’s Expert Panel

Trish RileyDirector, Maine Governor’s Office of Health Policy and Finance

Jane ClineCommissioner, West Virginia Office of Insurance


WHAT IS THE OVERALL VISION OF YOUR EXCHANGE?


One Exchange• Administrative efficiencies• Intersection of individuals / self-employed / small

business– Will subsidy eligible & employed in small business

join as individuals?• Purchasing clout

Trish Riley

Draft recommendations to new Governor & Legislature re: Exchange


Regional ExchangesThe ACA prescribes that an Exchange may operate in more than one State if—

(A) each State in which such Exchange operates permitssuch operation; and

(B) the Secretary approves such regional or interstateExchange.

• Benefits• Create larger risk pools• Create larger markets• Admin. economy of scale• Portability across borders

• Barriers:• Risk Pool dynamics• State regulator autonomy• State Mandated Benefits• Governance• Risk Adjustment

Jane Cline


Administrative Agreements States do not have to share risk pools or even borders to work together on the health insurance exchange

Adjacent and non adjacent states may find great savings, particularly on IT infrastructure, by entering into compacts to share exchange administrative functions

• Benefits• Leverage down vendor

costs• Share best practices• Share maintenance cost

• Barriers:• State autonomy• Exchange strategy

coordination• State procurement laws

Jane Cline


WHAT WILL THE GOVERNANCE STRUCTURE BE?


Maine’s Exchange Governance Options1. Non-Profit?

Pros• Least influenced by political

environment• Most nimble as it will not be

constrained by state procurement agencies and HR rules

• Potentially better able to compete for highly skilled staff

• It’s not government so some may trust it more

• Traditionally private functions may be easier to carry out

Cons• Hardest entity to ensure that

state priorities are being carried out

• May be difficult to coordinate across state and federal agencies

• Difficult entity for sharing confidential information

• Government still remains responsible for carrying out ACA, yet Governor and legislature have least accountability here

Trish Riley


Maine’s Exchange Governance Options2. Existing Government Agency?

Pros• Ensures state priorities and goals

are being met• Easiest coordination with federal

and other state agencies• Greatest opportunity to ensure

transparency and accountability to state

• Confidential information more easily shared across state agencies

• Director appointed by Commissioner or Governor

Cons• Agency led by Commissioner that

serves at the pleasure of the Governor• No diverse governing board to assist

with technical and policy issues• Don’t want to create new agency and

Exchange functions may get lost or downplayed in existing agency

• May carry stigma as governmental agency

• Most influenced by political environment

• Less nimble as it must follow state procurement and HR laws

Trish Riley


Maine’s Exchange Governance Options3. Independent / Quasi- State Agency?

Pros• Better site for state priorities• Easier to coordinate with federal

and state agencies• Better accountability and more

transparency• Can appoint governing board composed

of people with technical expertise• Board appointed by Governor and

Legislature• Executive Director to serve at pleasure of

the Board• Flexibility from some state procurement

and HR laws• May be better able to interact with private

sector than government agency

Cons• Sharing of confidential information may be

problematic• May carry stigma with consumers

(individuals and businesses) as governmental agency

• May be somewhat influenced by political environment

• Less able to ensure accountability and transparency to state government than full governmental entity

• Executive and Legislative branches of government have less control than over a state agency; more than over a non-profit

Trish Riley


Exchange GovernanceOptions concerning exchange governance:

• State Agency• Nonprofit created by

State• Federal

Regardless of governance, state entities must be engaged:

• Governor’s Office• Insurance Regulator• Medicaid• CHIP• Social Services• Public Health

Jane Cline


WV Exchange GovernanceGovernance Proposal

Recommended that HIX exist within the State’s insurance regulator

Recommended that HIX have board and that this board have autonomy to make policy decisions independent of the regulator

Recommendation Rationale• State Authority• Accountability to citizens• Administrative

streamlining• Regulatory Continuity• Board supported but

independent• Effective model already

exists

Jane Cline


HOW WILL YOU COORDINATE ELIGIBILITY AND

ENROLLMENT?


PROPOSALS FOR GOVERNOR-ELECT & NEW LEGISLATURE

Medicaid in an Exchange Environment400% FPL

138% Medicaid / DHHSIntegrated Eligibility System

0%

Exchange “Front Door”

PROPOSALS FOR GOVERNOR-ELECT & NEW LEGISLATURE

Trish Riley


Eligibility/Enrollment• Re-Think Medicaid & Subsidies

• Single front-door for subsidies, 0% – 400% FPL- MAGI

• Behind the scenes cascade into DHHS integrated delivery system• No wrong door – Can access subsidies / exchange via DHHS as

well

• Build on current capacityA. Medicaid Eligibility

• Integrated system with social services• Needs some modernization to comply with ACA• Needs to continue for Medicaid populations

B. Dirigo Health Agency• Website & calculator

• Subsidy eligibility & determination• Link to Medicaid

• (www.dirgohealth.maine.gov)• Developed added Exchange capacities via SHAP grant

(Vouchers)

Trish Riley

http://www.dirgohealth.maine.gov/�


Eligibility and EnrollmentHIX Eligibility Role

Exchange must inform individuals of eligibility for state’s Medicaid, CHIP, and federal subsidies.

Exchanges must also determine eligibility for mandate exemption

HIX Enrollment RoleExchange must establish a way to apply for enrollment in Medicaid, SCHIP

HHS will provide single streamlined form that may be used in applying for all applicable state health subsidy programs

Jane Cline


Options• Use Federal IT/Early Innovator• Have eligibility/enrollment for

public plans take place in current system with HIX MOU

• Develop two eligibility/enrollment doors (one public plans, one HIX)

• HIX develop new IT system as single entry point

• Hybrid of various options

Strategy • Work with stakeholders• Determine core functions• Maximize federal resources• Administratively and

operationally efficient• Ensure seamless and simple

for consumers• Do not compound confusion-

thoroughly test

Eligibility and Enrollment Systems

Jane Cline


WHAT TOOLS CAN YOU EMPLOY TO ACHIEVE

AFFORDABILITY?


• Impact of national plans?• Robust marketplace

– Patient Centered Medical Homes• Payment Reform Workgroup• Demos

AffordabilityTrish Riley


• Negotiate with plans for exchange premiums

• Allow market competition to drive plan premiums

• Through economy of scale, perform insurance administrative functions more efficiently

• Leverage exchange pool for lower provider payments

• Place price of using producer/ navigator on the consumer

• Limit number of plans available and drive down premiums through auction of plan slots

Mechanism for Cost Saving?Jane Cline


Exchange Planning Grant TIMELINE

Jane Cline


HOW WILL YOU ENGAGE STAKEHOLDERS?


Stakeholder Involvement

GovernorGovernor’s Office of

Health Policy & Finance

Senior Level Health Reform Implementation

Steering Committee

Subcommittees with Agency Staff

Legislature

Joint Select Committee onHealth Reform

Opportunities and Implementation

Advisory Council on Health Systems Development

(Advises Legislature and Governor) Funded in part by HRSA SHAP Grant

Trish Riley


Stakeholder Engagement• Address producer concerns• Engage consumers at every

level (individual, small group, large group)• Use focus groups to reach

underserved demographics• Don’t forget providers

• Must get buy-in from Governor• Must communicate with

constituent state agencies like CHIP, Medicaid• Engage Legislature• Engage carriers in

regulator/issuer meetings

Jane Cline


Stakeholder Strategy• Will have HIX request for

comment running concurrent to stakeholder meetings• After stakeholder meetings

will develop community of interest groups to focus on specific exchange issues• Will have focus groups to

ensure that consumer input incorporated into plan

• Continuously engage stakeholders on their own turf (quarterly/ annual meetings)• Setting up website to allow

consumers to see process behind HIX planning and research• Launching statewide

stakeholder meetings over next two months

Jane Cline


Questions and Answers

Please submit your questions through the chat function


www.nashp.org


www.SHAPaccess.org

State-developed resources:• State-Specific Overview Analyses

• Health Reform Work Plans, Timelines, and Progress Reports

• Coordinators and Coordinating Bodies

• Fiscal Analyses

• Proposals for Federal Funding

• State Laws, Rules, and Regulations

• State Implementation Websites

Share your implementation resources with us!Send to [email protected]

Check out Priority 1 for state exchange resources! Over 50 state exchange resources from 18 states now available.

www.statereforum.org


Please feel free to contact the SHAP team with any questions.

Thank You

Anne GauthierSenior [email protected]

Kathy WitgertProgram [email protected]

Christina MillerResearch [email protected]

Sonya SchwartzProgram [email protected]

Chris CantrellResearch [email protected]

mailto:[email protected]�





state to state exchange on health insurance exchanges

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