Federally-facilitated Exchange Partnership Planning in Arkansas: Where We’ve Been; Where We Are Now; and Lessons Lea

1. Federally-facilitated Exchange Partnership Planning in Arkansas: Where We’ve Been; Where We Are Now; and Lessons Learned Presented to Idaho Health Insurance Exchange Working Group October 9, 2012 Cynthia Crone, APN Arkansas Insurance Department

2. Arkansas Landscape • Low Per Capita Income • Poor Health Status Indicators • Large and Growing Percentage of Uninsured • Medicaid Deficit Expected in 2013 • Health Agency Leaders Working Together to Improve Health System

3. Arkansas Health System Improvements • Payment and Quality Transformation using Evidence-Based Episodes of Care PCMC Model • Workforce • Health Information Technology • Health Benefits Exchange

4. ACA and Arkansas Political Landscape • Popular Governor • Democrats are Majority in Legislature, Growing Number of Republicans • Vocal, Active TEA Party Republicans Opposed to ACA and therefore to Exchanges

5. Exchange Planning • Arkansas Insurance Department is Lead Agency • Commissioner is Governor Appointee and “Planning Authority” • Funding to Date • Exchange Planning • Level One Cooperative Agreements (2)

6. How Many Will Be Affected? • An estimated 572,000 Arkansans will be eligible for Exchange coverage beginning January 1, 2014. • It is conservatively estimated that: • 328,000 more nonelderly Arkansans will enroll (resulting in a 60% decrease in uninsured post-ACA). • There will be a $615 million reduction in uncompensated care among nonelderly (a 68% change post ACA). • There will be $478 million in federal subsidies provided for Arkansans to purchase insurance. Source: State Progress Toward Health Reform Implementation: Slower Moving States Have Much to Gain, Timely Analysis of Immediate Health Policy Issues, January 2012 Urban Institute analysis, HIPSM

7. “As Is” (Pre-ACA)(ACHI, 2012)

8. 2014 (Post ACA)(ACHI, 2012)

9. Development of Partnership Model • Arkansas did not obtain authority for State Exchange - 2011 • Arkansas did not seek Level One funding - September - 2011 • Partnership Option Announced by CCIIO - September 2011 • Exchange Planning Steering Committee recommended that “planning for a State Exchange end” - November 2011 • Obtained Governor’s approval to explore Partnership Model and apply for Level One Funding - December, 2011

10. Arkansas is Planning “Full” Partnership Model • Plan Management • Consumer Assistance • Medicaid – FFE Integration

11. Level One Funding “and Waiting” • First Level One funding award received February 2012 • Required to obtain Legislative Approval for Spending • While “waiting”… • Exchange Planning Grant No Cost Extension kept small staff operating • Designed Stakeholder Engagement Process • Designed Contractor/Staff Communication Process • Implemented Advanced Procurement and Hiring Activities • Level One Appropriation obtained April 20, 2012

12. Stakeholder Inclusion Operational Model Planning Staff & Advisory Committees Research / Alternatives Analysis Advisory Committees Develop Recommendations with Alternatives Steering Committee Final Recommendation to Commissioner

13. Steering Committee The Steering Committee meets once monthly and includes representation of the following: • Insurance Department (2) • Department of Human Services (2) • Arkansas Health Agency Leaders • Department of Finance & Administration • Advisory Committee Co‐Chairs (6) • State Legislature (2) • Governor’s Office • Stakeholders At Large (3)

14. Topic Calendars Consumer Assistance Nov IPA Ongoing Monitoring May May June June July July August August Sept Sept Oct Oct Essential Health Benefits IPA Eligibility Active Purchaser vs. Open Market IPA Certification & Recertification IPA Training Options Active Purchaser vs. Open Market IPA Application & Application Review Network Adequacy, Market Standard and Risk Pool Definition QHP Elements Application Submission and Transmission of Data Elements IPA Program Funding IPA Performance Metrics QHP Application & Certification Format and Content Plan Management

15. Consumer AssistanceIn-Person Assisters (IPAs) • Categories - Navigators - Enrollment Assisters - Licensed agents and brokers (producers) • Arkansas Insurance Department will: - Certify, recertify, decertify individual IPAs - Oversee IPA training and performance - Contract with IPA entities to facilitate enrollment and post- enrollment complaint resolution as needed

16. Consumer AssistanceOutreach and Education • Outreach Education • Two Phases Planned for 2012-2013 • Phase I – General ACA/Exchange Education • Phase II – Move Eligible Residents toward Enrollment • IPA Specialists through “Home Town Health” • Complaint Resolution • FFE Eligibility/Enrollment • AID Consumer Services Division

17. Current Outreach/Education - Phase I • Interagency Contracts UAMS • Opinion Poll to guide messaging for Phase I • Focus Groups to assist with “Naming/Branding” • Speakers’ Bureau • Initial Message Development/Media Buys U of A Partners for Inclusive Communities • County Meetings • Quarterly Updates • Stakeholder Summit • Staff/Consultants - IPA Outreach

18. In Person Assister (IPA) Entities • AID will contract with community-based IPA entities that will engage certified IPAs • We estimate 535 IPAs needed for initial Open Enrollment  decreasing to 134 until next Open Enrollment • Continuous, real-time feedback from the FFE will be critical in continuously assessing our successes and initiating needed improvements.

19. Key Dates and BenchmarksIn-Person Assisters • IPA IT vendor selection • IPA Program and Processes Defined by December 2012 • IPA RFP Complete by January 2013 • IPA RFP Advertised by February 2013 • IPA Awards by May 2013 • IPA Training by June 2013 • Certified IPAs in the Field July 2013 • Open Enrollment October 2013

20. Plan Management Activities • Select EHB Benchmark Plan • Define QHP Certification Criteria and Processes • Decrease financial start up risks for issuers • - Risk Adjustment • - Reinsurance (temporary) • - Risk Corridor (temporary)

21. Plan Management Processes • Leverage Existing Processes within AID where they exist: • Life and Health • Rate Review • Consumer Services • Finance • License • Legal • Use Enhanced SERFF System

22. EHB Benchmark Considerations • Compliance with ACA • Consumer Protection • Arkansas Health Needs • Overall Premium Costs and Value • State Mandated Benefits • Wellness Benefits • Other

23. EHB BenchmarkRule 103  Directive 2-2012 • Arkansas Blue Cross Blue Shield Health Advantage (POS) with following Substitutions: • QualChoice Federal Plan Mental Health and Substance Abuse Treatment Services • ARKids First (CHIP) Pediatric Dental • Blue Cross Blue Shield Federal Plan (Blue Vision High) for Pediatric Vision • Habilitative Services will likely be determined by carriers with State oversight

24. Selected Arkansas QHP Certification Criteria • Meet ACA Standards for Benefits and Actuarial Value • Increase Competition in Marketplace • Arkansas Specifics: • Will use a certification approach for plan selection. • Will not require network adequacy or quality standards that exceed federal ACA requirements in year one. • The Steering Committee acknowledges the emerging importance of Arkansas’s Payment Improvement Initiative in advancing quality and affordability and the Exchange may engage or require carriers to adopt specific quality improvement strategies as a condition of having their QHPs certified to be marketed and sold on the Exchange.

25. Selected Arkansas QHP Certification Criteria • Will not require carriers to offer their QHPs statewide as a condition of Exchange certification in year one, but recommends consideration of a regional approach with the goal of statewide coverage.* • Arkansas may limit the number of plans or benefit designs that may be offered by a carrier on the exchange.* • Pass on options related to incentivizing carriers. * Steering Committee recommended changes from PMAC recommendation.

26. Expected Rules • Network Adequacy • QHP Certification • In Person Assister Certification • More

27. Medicaid-Exchange Integration

28. Continuous Coverage AcrossInsurance Affordability Programs • How to mitigate negative effects of churning or family members in different plans • Plan to study options using data that evaluates costs and quality by benefit design, consumer demand, and provider capacity, to include: • Current FFS • QHP Option • Medicaid Plan Option • Bridge Plan

29. Summary of Exchange Planning to Date • Planning Grant – Background Research; Administrative Supplement to do Carrier Survey and more Quality Definitions • Level One A – Contractors and Staff to begin serious Plan Management and Consumer Assistance Planning • Level One B – Prepare for October 1, 2013 Open Enrollment and Full Implementation of Partnership Model by January 1, 2014; Study options to mitigate negative effects of IAP churning and promote continuity of coverage.

31. Key Milestones • Planning Review – May, 2012 • On Track; Big Take Away was that Partnership States would not issue Navigator Grants • Long-term financial sustainability model for FFE-P unknown • Design Review – October 1-2, 2012 • CCIIO/CMS staff very helpful; Arkansas waived out of most Blueprint items for Partnership Model • Federal officials willing to negotiate implementation issues with state; Long-term financial issues for FFE-P not completely resolved, but state must be “paid” for service • Blueprint Application and Declaration Letter – November 16, 2012 • “Think about long- term plans” • Collaborate with other states

32. Key Milestones • QHP and Navigator Certification and Operational Processes Design Complete by end of 2012 • DHHS Conditional Approval as Partnership FFE by January 1, 2013 • Implementation Review – Summer 2013 • Open Enrollment October 1, 2013 and Partnership Exchange is Fully Operational Covering Consumers by January 1, 2014 • The Future??

33. LESSONS LEARNED Building your team • Advance Planning for Hiring and Procurement • Carefully Plan Stakeholder Engagement Model; Attract Diverse and Strong Leaders • Integrate Contractors into Planning and Project Management • Utilize CCIIO Staff and Other Resources • Integrate with Other Health Improvement Initiatives • Be Persistent in Relationship Building

34. LESSONS LEARNED Building Consensus Keep on message: • “Arkansas will not have a State Exchange” • FFE Partnership provides Arkansas: • Ability to meet ACA deadlines for compliance with law • Opportunity to tailor Plan Management and Consumer Assistance components to meet needs of Arkansans • Local design and implementation of Consumer Services and Protections • Funding for connecting with FFE

35. LESSONS LEARNED • Partnership with Medicaid Agency is critical • Consider and document majority and minority opinions • Make decisions Move on • Keep consumer focus

36. Summary • Arkansas has a tremendous need for coverage expansion. • Cost, quality, and access improvements in Arkansas’s healthcare system will benefit all Arkansans. • The Partnership Exchange allows Arkansas Insurance Department to continue regulatory and consumer protection functions for our residents. • Intentional efforts to mitigate negative effects of churning and promote continuous coverage will be especially important with our population. • Transparency and inclusivity in planning is critical. • Keep consumer focus a priority.

37. Questions/Comments Cynthia.Crone@Arkansas.Gov 501‐683‐3634 www.hbe.arkansas.gov