New York Health Benefit Exchange Danielle Holahan Deputy Director IPRO June 4, 2013

1. New York Health Benefit ExchangeDanielle HolahanDeputy Director IPROJune 4, 2013

2. Topics for Today • What is the Exchange? • Who will Enroll through the Exchange? • Accomplishments to Date • Qualified Health Plan Certification Process • Health Plan Quality and Enrollee Satisfaction Requirements • Going Forward to October 1, 2013

3. What is an Exchange? • Organized marketplace • Easily compare health plan options • Makes available tax credits and cost-sharing subsidies • Easily enroll in qualified health plans • Two programs • Individual Exchange • Employer Exchange, which is called the Small Business Health Options Program, or “SHOP”

4. Functions of the Exchange • 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 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

5. Full Implementation Impact of Exchange and Reforms in New York • One million people will gain insurance • Exchange enrollment is estimated to be 1.1 million people: 450,000 615,000

6. Full Implementation Impact of Exchange and Reforms in New York Exchange Enrollment Individual Exchange – with Subsidy 43% SHOP Exchange 44% Individual Exchange – without Subsidy 15%

7. Enrollee Characteristics, by Income Source: Urban Institute, Characteristics of Nonelderly New Yorkers Likely to Enroll in the Health Insurance Exchanges Under the Affordable Care Act, February 2013.

8. Enrollee Characteristics, by Language Note: Includes enrollees over 5 years of age. Source: Urban Institute, Characteristics of Nonelderly New Yorkers Likely to Enroll in the Health Insurance Exchanges Under the Affordable Care Act, February 2013.

9. Enrollee Characteristics, by Language Note: Includes enrollees over 5 years of age. Source: Urban Institute, Characteristics of Nonelderly New Yorkers Likely to Enroll in the Health Insurance Exchanges Under the Affordable Care Act, February 2013.

10. Impact of Exchange and Health Reform in New York

11. SHOP – the Value Propositions

12. Key Accomplishments to Date • Contracted with customer services organization • Invited Health Plans to Participate in the Exchange • Invited organizations to apply to be In-Person Assistors/Navigators • Received conditional certification from HHS in December2012 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

13. IPA/Navigator RFA Released February 13, 2013 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

14. Grassroots Outreach Goals: • Build public awareness of the Exchange • Build support, educate and earn by-in from organizations who work with targeted populations • Educate individuals and small businesses about health insurance and the benefits of enrolling in the Exchange • Actively focus outreach efforts on the most vulnerable and difficult to reach populations and address their needs and concerns • Drive potential enrollees to an enrollment mechanism including online, by phone, in-person and by mail

15. Health Plan Invitation Released January 31, 2013 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

16. 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 Insurer must agree to participate in its entire approved Service Area, unless granted an exception by the Exchange

17. QHP Standard Products Insurers Must Offer: 1 standard product, at every metal level, in every county of their service area that includes the Essential Health Benefits A standard Child only product, at every metal level A standard Catastrophic product If there is more than one catastrophic product offered in a county, the Exchange may allow QHPs the option of not offering this product Pediatric dental benefits, as a separately priced benefit for each standard and non-standard product proposed If sufficient Stand-alone Dental products are available, QHPs may elect not to offer pediatric dental

18. QHP Non-Standard Products Insurers May Elect to Offer: Up to 3 non-standard plans, per metal level Non-standard product means: Additional benefits not included in the Essential Health Benefits Insurers may substitute benefits in the following EHB categories: Preventive/Wellness/Chronic Disease Management Rehabilitation/habilitation Standard product with a different provider network Variations on standard cost sharing Issuers may elect to offer non-standard products in a portion of their Service Area

19. Out-of-Network (OON) Benefits • OON benefit will be required to ensure that consumers have the same choices in the Exchange as in the outside market • If an Insurer offers an OON product outside the Exchange in a county, Insurer is required to offer an OON product inside the Exchange in the same county • Must be offered at the Silver and Platinum levels

20. Network Adequacy All QHP and Stand-Alone Dental Products will be subject to network adequacy test Requirements will initially mirror those used by DOH for HMO products QHPs will be required to use “best efforts” to contract with Essential Community Providers and, at a minimum, must include one FQHC and one tribal operated health clinic in each county to the extent one is available All plans must submit provider networks on a quarterly basis; over time, will be required on a monthly basis Network information will be available to consumers during the plan selection process

21. Quality and Enrollee Satisfaction • All QHPs must adhere to the following five criteria in order to demonstrate quality of care and enrollee satisfaction: • 1) Develop and maintain a quality strategy that is updated annually with progress reported to DOH • 2) Participate in DOH Quality Assurance Rating Requirements (QARR) • Quality indicators in QARR are primarily adopted from the National Committee for Quality Assurance (NCQA ) Health Care Effectiveness Data and Information Set (HEDIS), with NYS specific measures included • QARR submissions with respect to Exchange enrollment is anticipated to begin on or around June 2015 for calendar year 2014 • All QHPs must have: • HEDIS Volume 2, programming for all required measures (either in-house capability of through a vendor), • An NCQA audit conducted by a licensed audit organization of their QARR data prior to submission to the DOH, and • A certified CAHPS vendor to administer CAHPS www.HealthBenefitExchange.ny.gov

22. Quality and Enrollee Satisfaction (continued) • 3) Conduct an annual survey of eligible members using the standardized Consumer Assessment of Health Care Providers (CAHPS) tool • Initial CAHPS survey anticipated to be scheduled on or around fall of 2014 • 4)Develop an infrastructure that allows for the implementation of quality initiatives • Includes administration of member services, offering member outreach/education or incentive programs, offering physician training and/or incentive programs, supporting systematic changes at the practice level, etc • 5) Meet Accreditation requirements when required by the Exchange www.HealthBenefitExchange.ny.gov

23. 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 are due May 15th Anticipated notification of Certification is July 15, 2013

24. 7 Things You Need to Know: • New affordable and comprehensive health insurance options will be available for New Yorkers • Open enrollment begins October 1, 2013 for coverage that begins January 1, 2014 • If you earn less than $45,960 as an individual or $94,200 for a family of 4, you may be eligible for financial assistance that will make coverage more affordable • You will not be denied health insurance on the basis of a pre-existing condition (continued…)

25. 7 Things You Need to Know (continued): • All health insurance options will offer a comprehensive array of services • Preventive services will be offered at no cost to you • You can get help enrolling in coverage: • Call center • In-person assistor (Navigator or broker) • On-line via web chat • You pick the plan that is best for you: • Compare your plan choices based on price, provider network, or quality score

26. Exchange Timeline Executive Order Issued - April 2012 NY completes HHS Design Review - October 2012 NY submits Blueprint to HHS – November 2012 NY receives conditional certification from HHS to operate a state-based Exchange - December 2012 Grassroots Outreach activities begin - April 2013 Health Plans Selected for participation in 2014 - July 2013 In-Person Assistor/Navigator Program begins – September 2013 Customer Service opens for business – September 2013 Advertising Campaign launched – September 2013 Applications accepted – October 2013 Coverage starts – January 2014

27. www.HealthBenefitExchange.ny.gov