Implementing Plan Management in the Delaware State Partnership Marketplace

1. Implementing Plan Management in the Delaware State Partnership Marketplace Presentation to the NAIFA-Delaware May 15, 2013

2. Delaware’s State Partnership Marketplace • In 2012 Delaware opted to implement a State Partnership Marketplace to serve Delaware’s individual and small group markets. • This decision resulted from the State’s analysis of implementation feasibility and financial risk to the State under each available model. • The State Partnership Marketplace will allow the State to retain management of both the qualified health plans offered on the marketplace, as well as in-person consumer assistance and outreach functions. • These functions are the “consumer facing” areas of the marketplace and have the greatest personal impact on Delawareans. • In December 2012, Delaware became the first state to receive conditional approval for State Partnership Marketplace implementation.

3. Delaware’s Marketplace Goals The State identified specific goals and objectives that inform the critical decisions made regarding Marketplace-related policies, processes and implementation approach, as well as provide a marker for Marketplace performance measurement. Goals: • Improve access to affordable health insurance for Delawareans. • Achieve financial sustainability that does not adversely impact the Delaware insurance market (carrier selection and cost of coverage). • Assist small employers with the purchase of insurance for their employees. • Implement a model that harmonizes with the broker community. • Comply with federal regulations and guidelines for a State Partnership Model for Plan Management and Consumer Assistance.

4. Delaware’s Partnership Marketplace States were given some flexibility in defining their own “Partnership” Marketplace. Under its Partnership model, Delaware will: • Implement both Plan Management & Consumer Assistance functions • Conduct final eligibility determination for Medicaid/CHIP for individuals who apply through the Federal Marketplace portal • Defer Reinsurance program administration to federal government • Establish a state-specific Essential Health Benefits (EHB) benchmark • Establish state-specific QHP certification standards in addition to federal QHP requirements • Retain separation between the Individual and Small Group markets

5. Federal Responsibilitiesin the FPM Key Exchange functions and responsibilities retained by HHS in the FFE State Partnership Marketplace model include: • Final certification of QHPs • Development and operations of the Marketplace Website • Eligibility determinations for premium subsidies (APTCs and CSRs) • ‘Shop and Compare’ and Enrollment in QHPs • Operation of the SHOP to support small group employers/employees • Financial management, including premium aggregation, billing, audits, etc. • Reinsurance and Risk Adjustment • Call Center Customer Support functions

6. Delaware’s Cross-Agency Approach • Lead State Agencies: • Delaware Department of Health and Social Services—Lead Agency • Delaware Insurance Department—Regulate insurance and lead operational functions for plan management and in-person consumer assistance • Health Care Reform Committee (HCR) – Cross-agency/program steering committee that provides strategic and policy-level leadership, and ensures efficient and appropriate integration among state agencies • Delaware Health Care Commission–The HCC reviews and approves Exchange-related policies and ensures that the Exchange aligns and supports the state’s overall health reform goals and objectives. In addition, Delaware continues works closely with CMS/CCIIO to develop strategies and processes to support programmatic and system integration within the Partnership model.

7. Plan Management: Department of Insurance The Marketplace Team has: • Identified operational requirements for marketplace plan management. • Interaction with DHSS and Federal partners and the interagency division of responsibilities. • Established DOI divisional roles and responsibilities and identified key marketplace personnel. • Developed business processes and standard operating procedures (SOPs) for plan management functions. SOPs are currently being finalized to QHP oversight and monitoring, and in-person consumer assistance.

8. Building operational capacity for PM activities Delaware is leveraging its existing operational structure and staff to support Plan Management activities, including: • Collect and review Issuer and plan data to support QHP certification, • Collect and transmit necessary data to HHS • Conduct QHP Issuer Account Management activities in coordination with HHS • Perform QHP oversight and monitoring • Collect additional Issuer data as required to support oversight and quality reporting • Verify accreditation status • Track and resolve consumer complaints and inquiries • Coordinate with HHS on quality rating and enrollee satisfaction survey The DOI has hired additional, dedicated staff, and is developing additional tools and procedures to support those PM activities that do not easily align or naturally ‘fit’ within the current agency practices.

9. In-Person Consumer Assistance • The Delaware Marketplace will coordinate with a variety of organizations and entities to educate consumers on insurance affordability programs, and to apply for and enroll in coverage. • Consumers will be assisted in a variety of ways: • In person • Online • By telephone Delaware Health Benefit Exchange

10. Consumer Assistance • All assisters, with the exception of agents/brokers, are required to provide unbiased responses to Marketplace inquiries. • For example, they can explain the various components (benefits, rates, premiums, etc.), but cannot advise on which is ‘best’ for the consumer or influence their decision. Delaware Health Benefit Exchange

11. Agent/Broker Participation • Agents/brokers participating in the Marketplace will • Assist consumers in completing the eligibility application • Compare and select QHPs • Enroll consumers • While producers will serve both the Individual and Small Group markets, the state anticipates that agents and brokers will play a critical role in helping qualified employers and employees enroll in coverage through the Small Business Health Options Programs (SHOP) Delaware Health Benefit Exchange

12. Agent/Broker Commissions in the Marketplace • QHP Certification standards require Issuers to pay the same agent and broker compensation for enrollment through the Marketplace/SHOP and for enrollment of similar health plans offered outside the Marketplace/SHOP • Delaware is not permitted to establish a commission schedule or pay commissions directly to agents/brokers • The Marketplace will transmit agent/broker identifying information (Marketplace ID and the agent’s or broker’s national producer number-NPN) to Issuers to facilitate payment of appropriate compensation. Delaware Health Benefit Exchange

13. Agent/Broker Registration and Training • Since Delaware is a Federal Partnership State, CMS will be responsible for registering and training agent and brokers • Registration Process: • Confirm his/her identify by answering in an online form • Complete a Marketplace-specific online training course • Agree to comply with federal and state laws, rules, standards and policies, • Sign a privacy and security agreement with CMS, and • Obtain a Federally-facilitated Marketplace ID. • The DOI will continue to license and regulate producers in Delaware; and may require state-specific training to supplement the federal training modules. • CMS anticipates Agent/Broker registration and training to begin in mid Summer. Delaware Health Benefit Exchange

14. QHP Standards • As prescribed in the PPACA, all Issuers and plans participating in the Marketplace must meet federal certification standards for Qualified Health Plans. The Final Rule regarding federal standards for QHPs may be found on the Federal Register at the following URL: https://www.federalregister.gov/articles/2012/07/20/2012-17831/patient-protection-and-affordable-care-act-data-collection-to-support-standards-related-to-essential

15. Delaware QHP Standards In addition to the Federal QHP standards, Delaware chose to include some additional standards. Highlights include: • Requirements for a state-wide Rating Area and Service Area that expands provider coverage throughout the entire state and mitigate the risk for adverse selection • Network Adequacy standards that align with Medicaid and Department of Public Health standards • Issuer-required Transition Plans that support continuity of care for consumers as they move from QHPs to Medicaid and vice-versa • Quality Improvement Strategies, including a requirement that all Issuers participate, at the prevailing rate, in the Delaware Health Information Network (DHIN) • Essential Community Provider standards that include contracting with federally-qualified health centers (FQHCs) and providing reimbursement of these centers at the appropriate rates

16. Delaware QHP Standards The State followed a number of guidelines in developing its QHP Standards, including: • All plans, both inside and outside of the Marketplace, must comply with EHB benchmarks established by the state, with certain exceptions for stand-alone pediatric dental plans. • All state-specific QHP Certification Standards will apply to both Individual and Small Group (SHOP) plans sold inside the Marketplace. • All QHPs must comply with existing federal standards and regulations, including those within the ACA as well as other federal requirements, such as Mental Health Parity.

17. Proposed Delaware QHP Timeline • March 28, 2013 Application period opened for Issuers • May 30, 2013 applications for QHPs are due • June 15, 2013 rates for QHPs are due • July 31, 2013 recommendations for certification are due • August, 2013 1 week period for Issuers to review what is posted on portal • September 2013 contracts signed • October 1, 2013, open enrollment begins • March 2013 open enrollment ends

18. QHP Review and Certification • The DOI’s approach to QHP review and certification leverages existing agency business unit reviews, federal processes and tools that are integrated into an over-arching operational procedure. • DOI will conduct QHP certification reviews for compliance with state and federal standards and regulations for: • Licensure and good standing • Service area • Network adequacy • Essential community providers • Marketing oversight • Accreditation • Essential health benefits standards • Actuarial value standards, including variations for cost-sharing reductions, as well as cost-sharing limits • Discriminatory benefit design • Benefits for meaningful difference among similar plans, and • Rates (new and increases), including compliance with rating reforms

19. Multi-State Plans • The State would welcome multi-state plans to increase competition in the Marketplace and provide Delawareans with more choices for affordable health plans • DOI is meeting with OPM to discuss the state’s potential inclusion in Year 1 roll-out • OPM has reviewed our state-specific standards and does not anticipate any conflicts with federal guidelines.

20. Critical Success Factors • Embracing a culture of coordination and collaboration among state and federal organizations • Continually engaging the broad stakeholder community • Ensuring that Delaware Marketplace policies and practices support the state’s overall health care reform goals and initiatives

21. Information Resources • Federal resources • www.Healthcare.gov • www.cms.marketplace.gov • http://www.dol.gov/ebsa/healthreform/ • http://www.sba.gov/healthcare • Delaware Resources • Department of Insurance: http://www.delawareinsurance.gov/health-reform/DEMarketplace.shtml • Delaware Health Care Commission: http://dhss.delaware.gov/dhcc/ • Additional Agent and Broker federal guidance • www.cciio.cms.gov/resources/regulaltions/Files/Agent-broker-5-1-2013 Delaware Health Benefit Exchange