health benefit exchange update kelly smith – director, shop exchange sherry tomasky - director,...
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![Page 1: Health Benefit Exchange Update Kelly Smith – Director, SHOP Exchange Sherry Tomasky - Director, Stakeholder Engagement Northeast NAHU Presentation June](https://reader036.vdocument.in/reader036/viewer/2022062515/56649cc45503460f9498e0b5/html5/thumbnails/1.jpg)
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Health Benefit Exchange Update
Kelly Smith – Director, SHOP ExchangeSherry Tomasky - Director, Stakeholder Engagement
Northeast NAHU Presentation
June 13, 2013
![Page 2: Health Benefit Exchange Update Kelly Smith – Director, SHOP Exchange Sherry Tomasky - Director, Stakeholder Engagement Northeast NAHU Presentation June](https://reader036.vdocument.in/reader036/viewer/2022062515/56649cc45503460f9498e0b5/html5/thumbnails/2.jpg)
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
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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
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Functions of the Exchange
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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
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
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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
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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
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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.
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• 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
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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
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
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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
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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
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Consumer Assistance and Enrollment
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• 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
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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
Sherry TomaskyDirector, Stakeholder Engagement