Pre-Existing Condition Insurance Plan “HealthBridge NY”

1. Pre-ExistingConditionInsurance Plan“HealthBridge NY” New York State Insurance Department Eileen Hayes Health Bureau

2. Timetable • New York submitted its proposal to operate the Pre-Existing Condition Health Plan (PCIP) on July 1, 2010. • HHS to contract with GHI directly; anticipated to occur in August. • New York anticipates to begin accepting applications in late August. • Coverage to begin in the fall.

3. New York’s Proposal • Group Health Incorporated (GHI) must be approved by HHS to operate the PCIP in New York. • GHI, a subsidiary of Emblem Health, is the only nonprofit company authorized to operate statewide in NYS.

4. New York’s Proposal Continued • HHS to contract directly with GHI • MOU to address administration of the program and New York’s unique consumer protections. • New York will follow Federal law and HHS guidelines on eligibility for the program (slide 3).

5. Eligible Individual • To be eligible, an individual must: • Be a citizen or national of the U.S. or be lawfully present; • Not have had creditable coverage for the previous 6 months prior to applying; and • Have a pre-existing condition as determined in “a manner consistent” with guidance from the Secretary of HHS.

6. Proof of Eligibility • Not much flexibility was afforded the eligibility criteria. • Proof of citizenship, national of the U.S., or lawfully present must have supporting documentation (no attestation); • NY is researching a cross-reference to the Social Security data to reduce the burden of ensuring this criterion is met. • Proof of no insurance for the previous 6 months will likely be shown by attestation; • no exceptions for those who are underinsured or who have lost coverage through no fault oft their own; and • Proof of a pre-existing condition must have supporting documentation; • We are urging increased flexibility; use of a health risk assessment. Want to avoid a requirement that the applicant will have to show medical proof of a condition potentially calling for a visit to a provider at their own cost. New Yorkers will not have a rejection letter from an insurance company to meet this burden.

7. Benefit Package Continued • An exclusive provider program (“EPO”) design has been selected. • Members will pay only a small co-pay for most covered services received from in-network providers including preventive care. • In the event an in-network provider is unavailable, out of network coverage for the service will be provided at no additional cost to the consumer.

8. Benefit Package • PCIP coverage will include NY’s consumer protections. • The benefit package will be comprehensive and include all benefits that are mandated by New York State law and the 9/23/2010 effective PPACA benefit enhancements. • The package will include coverage for inpatient and outpatient hospital coverage, mental health, alcoholism and substance abuse, home health care, skilled nursing services, rehabilitative services, laboratory and radiology services, maternity, office and specialist visits, preventative care, chiropractic, speech therapy, durable medical equipment, vision and prescription drugs.

9. Cost Sharing Access to necessary, cost efficient care • Inpatient Copay -$500 per confinement • Ambulatory Surgery Copay - $250 • Emergency Copay - $100 waived if admitted • Physician/Specialist - $20 • Prescription Drugs • $0 Generic, • $10 Brand • $0 Mail Order Generic (90 day) • $20 Mail Order Brand (90 day) Actuarial value exceeds the required 65% Meets the out of pocket cost sharing limit of $5,950.

10. Premium Rates • New York had to develop a standard premium rate. The federal government pays claims that exceed the amount that a standard premium supports. • New York is a guarantee issue state with open enrollment and pure community rating in the individual and small group markets. New York's small group market covers approximately 1,700,000 lives and is consistent with the target population of the PCIP. The benefits are similar as well. Therefore the small group market was used to develop the standard rate. • New York also proposed using 90% of the standard rate because the standard small group rate in New York State is higher than it would be in states engaging in underwriting. As a result, New York has proposed a monthly premium of $362 upstate and $421 for the PCIP.

11. Consumer Protections • Members will be provided the same consumer protections as available in other NYS products including external appeal rights. • Members will have the ability to appeal eligibility determinations as well as coverage determinations.

12. Customer Service • Applicants and members will have access to many forms of consumer service, including Emblem Health’s current consumer services. • Phone • Internet • Walk-in centers • Pharmacy Help Desk • Available for members and physicians • Outreach, education and enrollment materials will be created for the program.

13. Conclusion • Contract to be finalized with HHS and GHI • MOU – NYS, HHS and GHI • Applications to be accepted in mid-August. • Coverage to be provided by the fall. • Expect to enroll in excess of 14,000 people with the resources provided. • Enrollment will be capped and a wait list will be established if and when demand for the program exceeds available funds.