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

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topics for today
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
slide3

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”
slide4

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
slide5

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

slide6

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%

slide7

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.

slide8

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.

slide9

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.

slide12

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

slide13

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
grassroots outreach
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
slide15

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

insurer requirements

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

qhp standard products

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

qhp non standard products

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

out of network oon benefits
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
network adequacy

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

slide21

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

slide22

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

qhp certification process and timeline

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

7 things you need to know
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…)

7 things you need to know continued
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
slide26

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