Final Exchange Rules: Preliminary Review

1. Final Exchange Rules:Preliminary Review Presentation to the Exchange Advisory Committee March 19, 2012

2. HHS Issued Final Exchange Rules on March 12, 2012 • Incorporates two proposed rules: • Exchange establishment proposed rule (issued 7/15/2011) • Exchange eligibility proposed rule (issued 8/17/2011) • LONG – 644 pages; • Received over 24,000 comments • Nearly 2000 were substantive • Responded to many of Vermont’s comments

3. Topics Addressed by Rule • General requirements related to Exchange establishment • Eligibility determinations • For QHP enrollment • Premium tax credits • Cost-reduction payments • Medicaid eligibility assessments • Enrollment of individuals in a QHP • SHOP Exchange • Including employer interactions • QHP requirements and certification

4. Additional Comments to be Accepted • Several provisions within the rule are issued as interim final rules and comments will be accepted until May 11, 2012 (45 days from publishing date of March 27, 2012) • Ability of state to permit agents & brokers to assist individuals in applying for assistance • Medicaid and CHIP regulations • Options for conducting eligibility determinations • Eligibility standards for cost-sharing • Timeliness standards for eligibility determinations • Verification for applicants with special circumstances • Timeliness standards for transmission of information for administration of advanceable premium tax credits and cost-sharing reductions • Agreements between agencies administering insurance affordability programs

5. Some Questions Still Unanswered • Considered less urgent by HHS, including: • How quality of Qualified Health Plans (QHPs) will be assessed • Exchange appeals process • Some issues will be addressed through guidance, including: • Languages for notice translation • How federally-facilitated Exchange will work

6. HHS Overview of Rule • Granted states flexibility in Exchange design • Many decisions left to state Exchanges • Exchange plans won’t face as rigorous review as Medicaid state plans do • Differ from preliminary rules: • States can have HHS determine eligibility for subsidies • States can have Medicaid agency determine eligibility who may be eligible for Medicaid/CHIP • States cannot allow insurance agents to determine eligibility for subsidies, but can assist with health plan options • HHS can grant conditional approval (in January 2013) to states that show likely to be fully operational by October 2013

7. Notable Provisions: Governance and Financing • Exchange Advisory Board: • Requires additional representation • Will request changes in H.559 to allow expanded membership • Must include a large employer (Act 48 only requires small businesses) • Must include representatives from brokers (Act 48 ambiguous) • Financing of the Exchange • Broad state flexibility in how to do this after 2015

8. Notable Provisions: Navigators • Requires that states have at least two categories of Navigators, and that one of them be a consumer or community focused non-profit • States must adopt conflict of interest standards • Navigators may not receive any compensation for enrolling individuals or employers in health insurance either in/out of the Exchange • Clarifies that Navigators cannot determine eligibility for subsidies – both eligibility determination and final enrollment must be done by State

9. Notable Provisions: Brokers • Exchange may allow brokers to enroll employers and employees in QHPs in the Exchange • Separate from navigator system • May also allow brokers to enroll individuals in QHP & tax credits by using the Exchange website • Add’l requirements not summarized here, including special training, etc.

10. Notable Provisions: Eligibility • Extensive eligibility provisions • Goal of rule is to create seamless, integrated application and determination process for Medicaid, CHIP, or premium tax credits • Applications to be processed based on existing data or attestations, where possible • Can use documentation other than tax records where “substantial change” in income • Must be able to accept applications and enroll in person • Annual redeterminations

11. Notable Provisions: Enrollment • Initial enrollment expanded by a month to March 31, 2014 • Annually, open enrollment shall be from October 15 to December 7 • States may add “exceptional circumstances” to special enrollment reasons • Coverage begins at the beginning of the next month if enrollment occurs by the 15th of the month (proposed rule said 22nd) • Can have be later if all plans in area agree AND • Enrollee agrees to forgo assistance for that month

12. Notable Provisions: Small Employer Exchange • Must include a premium calculator for employees • Aggregated bill must include total due, and breakdown of employer/employee split • Employer size calculation not finalized in the rule • Vt’s current definition is ok • Specifically allows small businesses to stay in the Exchange if they grow beyond 50 (or 100)

13. Notable Provisions: QHPs • State flexibility to be active purchase or to follow any willing insurer model • Encourage states to leverage existing rate review processes • Requires QHPs to submit justifications prior to implementing • Must meet network adequacy • Must follow state marketing rules • Provider directories must be available to the Exchange • Exchanges are encouraged, but not required, to consolidate directories

14. Notable Provisions: QHPs • Standalone dental plans cannot have annual or lifetime dollar limits • Must offer at least pediatric, can offer more • Requires QHPs to cover first month of consumer non-payment • Second and Third month can “pend” and if consumer pays late, QHP must still cover • If consumer does not pay, enrollment denied, and QHP must refund tax credits received • Multi-state plans • Must accept multi-state plans as certified by OPM • Doesn’t address state laws only Exchange qualifications • Stay tuned from future rules from Office of Personnel Management • Concerns should be directed to OPM

15. Questions? Robin Lunge Director of Health Care Reform Robin.Lunge@state.vt.us www.hcr.vermont.gov