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State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
State to State Exchange on Health Insurance Exchanges
Supported by the Health Resources and Services Administration
Monday, November 22, 2010 This event will begin at 1:30pm Eastern
Please hold until Anne Gauthier starts the conferenceThe audio portion of this web event can be accessed by dialing
800-269-3762
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Agenda1:30-1:35pm Welcome
Anne Gauthier, Senior Fellow, NASHP
1:35-1:50pm Overview of Key Exchange Design IssuesSonya Schwartz, Program Director, NASHP
1:50-2:35pm Interview About Current Exchange ThinkingTrish Riley, Director, Maine Governor’s Office of Health Policy and Finance
Jane Cline, Commissioner, West Virginia Office of Insurance2:35-2:55pm Question and Answer with Audience
2:55-3:00pm Wrap Up
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Overview of Key Design Issues
Sonya SchwartzProgram Director, NASHP
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Design Issue #1: Overall Vision
• Sub-state, state, regional, or federal option?
• One exchange or two (one for small business, one for individuals) ?
• Allow all plans to participate or select plans that meet certain standards?
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Design Issue #2: Governance
• New or existing stateexecutive branch agency under the Governor?
• Quasi public entity governed by a Board?
• State-established non-profit?
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Design Issue #3: Eligibility and Enrollment Systems
• One system or interface that links separate systems?
• Who will develop it and where will it sit?
• How does it link to Medicaid, CHIP and other programs?
• How do states develop the information technology resources?
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Design Issue #4: Tools to Achieve Affordability
• Exchange as market organizer or active purchaser?
• Rewarding or encouraging high value plans or delivery system reforms?
• Use tools to prevent adverse selection?
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Design Issue #5: Stakeholder Engagement
• Use the governing entity as a tool for involving stakeholders?
• Hold public hearings on major decisions?
• Opportunities for public comment on proposals?
• Feedback loop?
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Today’s Expert Panel
Trish RileyDirector, Maine Governor’s Office of Health Policy and Finance
Jane ClineCommissioner, West Virginia Office of Insurance
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
WHAT IS THE OVERALL VISION OF YOUR EXCHANGE?
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
One Exchange• Administrative efficiencies• Intersection of individuals / self-employed / small
business– Will subsidy eligible & employed in small business
join as individuals?• Purchasing clout
Trish Riley
Draft recommendations to new Governor & Legislature re: Exchange
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Regional ExchangesThe ACA prescribes that an Exchange may operate in more than one State if—
(A) each State in which such Exchange operates permitssuch operation; and
(B) the Secretary approves such regional or interstateExchange.
• Benefits• Create larger risk pools• Create larger markets• Admin. economy of scale• Portability across borders
• Barriers:• Risk Pool dynamics• State regulator autonomy• State Mandated Benefits• Governance• Risk Adjustment
Jane Cline
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Administrative Agreements States do not have to share risk pools or even borders to work together on the health insurance exchange
Adjacent and non adjacent states may find great savings, particularly on IT infrastructure, by entering into compacts to share exchange administrative functions
• Benefits• Leverage down vendor
costs• Share best practices• Share maintenance cost
• Barriers:• State autonomy• Exchange strategy
coordination• State procurement laws
Jane Cline
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
WHAT WILL THE GOVERNANCE STRUCTURE BE?
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Maine’s Exchange Governance Options1. Non-Profit?
Pros• Least influenced by political
environment• Most nimble as it will not be
constrained by state procurement agencies and HR rules
• Potentially better able to compete for highly skilled staff
• It’s not government so some may trust it more
• Traditionally private functions may be easier to carry out
Cons• Hardest entity to ensure that
state priorities are being carried out
• May be difficult to coordinate across state and federal agencies
• Difficult entity for sharing confidential information
• Government still remains responsible for carrying out ACA, yet Governor and legislature have least accountability here
Trish Riley
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Maine’s Exchange Governance Options2. Existing Government Agency?
Pros• Ensures state priorities and goals
are being met• Easiest coordination with federal
and other state agencies• Greatest opportunity to ensure
transparency and accountability to state
• Confidential information more easily shared across state agencies
• Director appointed by Commissioner or Governor
Cons• Agency led by Commissioner that
serves at the pleasure of the Governor• No diverse governing board to assist
with technical and policy issues• Don’t want to create new agency and
Exchange functions may get lost or downplayed in existing agency
• May carry stigma as governmental agency
• Most influenced by political environment
• Less nimble as it must follow state procurement and HR laws
Trish Riley
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Maine’s Exchange Governance Options3. Independent / Quasi- State Agency?
Pros• Better site for state priorities• Easier to coordinate with federal
and state agencies• Better accountability and more
transparency• Can appoint governing board composed
of people with technical expertise• Board appointed by Governor and
Legislature• Executive Director to serve at pleasure of
the Board• Flexibility from some state procurement
and HR laws• May be better able to interact with private
sector than government agency
Cons• Sharing of confidential information may be
problematic• May carry stigma with consumers
(individuals and businesses) as governmental agency
• May be somewhat influenced by political environment
• Less able to ensure accountability and transparency to state government than full governmental entity
• Executive and Legislative branches of government have less control than over a state agency; more than over a non-profit
Trish Riley
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Exchange GovernanceOptions concerning exchange governance:
• State Agency• Nonprofit created by
State• Federal
Regardless of governance, state entities must be engaged:
• Governor’s Office• Insurance Regulator• Medicaid• CHIP• Social Services• Public Health
Jane Cline
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
WV Exchange GovernanceGovernance Proposal
Recommended that HIX exist within the State’s insurance regulator
Recommended that HIX have board and that this board have autonomy to make policy decisions independent of the regulator
Recommendation Rationale• State Authority• Accountability to citizens• Administrative
streamlining• Regulatory Continuity• Board supported but
independent• Effective model already
exists
Jane Cline
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
HOW WILL YOU COORDINATE ELIGIBILITY AND
ENROLLMENT?
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
PROPOSALS FOR GOVERNOR-ELECT & NEW LEGISLATURE
Medicaid in an Exchange Environment400% FPL
138% Medicaid / DHHSIntegrated Eligibility System
0%
Exchange “Front Door”
PROPOSALS FOR GOVERNOR-ELECT & NEW LEGISLATURE
Trish Riley
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Eligibility/Enrollment• Re-Think Medicaid & Subsidies
• Single front-door for subsidies, 0% – 400% FPL- MAGI
• Behind the scenes cascade into DHHS integrated delivery system• No wrong door – Can access subsidies / exchange via DHHS as
well
• Build on current capacityA. Medicaid Eligibility
• Integrated system with social services• Needs some modernization to comply with ACA• Needs to continue for Medicaid populations
B. Dirigo Health Agency• Website & calculator
• Subsidy eligibility & determination• Link to Medicaid
• (www.dirgohealth.maine.gov)• Developed added Exchange capacities via SHAP grant
(Vouchers)
Trish Riley
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Eligibility and EnrollmentHIX Eligibility Role
Exchange must inform individuals of eligibility for state’s Medicaid, CHIP, and federal subsidies.
Exchanges must also determine eligibility for mandate exemption
HIX Enrollment RoleExchange must establish a way to apply for enrollment in Medicaid, SCHIP
HHS will provide single streamlined form that may be used in applying for all applicable state health subsidy programs
Jane Cline
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Options• Use Federal IT/Early Innovator• Have eligibility/enrollment for
public plans take place in current system with HIX MOU
• Develop two eligibility/enrollment doors (one public plans, one HIX)
• HIX develop new IT system as single entry point
• Hybrid of various options
Strategy • Work with stakeholders• Determine core functions• Maximize federal resources• Administratively and
operationally efficient• Ensure seamless and simple
for consumers• Do not compound confusion-
thoroughly test
Eligibility and Enrollment Systems
Jane Cline
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
WHAT TOOLS CAN YOU EMPLOY TO ACHIEVE
AFFORDABILITY?
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
• Impact of national plans?• Robust marketplace
– Patient Centered Medical Homes• Payment Reform Workgroup• Demos
AffordabilityTrish Riley
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
• Negotiate with plans for exchange premiums
• Allow market competition to drive plan premiums
• Through economy of scale, perform insurance administrative functions more efficiently
• Leverage exchange pool for lower provider payments
• Place price of using producer/ navigator on the consumer
• Limit number of plans available and drive down premiums through auction of plan slots
Mechanism for Cost Saving?Jane Cline
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Exchange Planning Grant TIMELINE
Jane Cline
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
HOW WILL YOU ENGAGE STAKEHOLDERS?
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Stakeholder Involvement
GovernorGovernor’s Office of
Health Policy & Finance
Senior Level Health Reform Implementation
Steering Committee
Subcommittees with Agency Staff
Legislature
Joint Select Committee onHealth Reform
Opportunities and Implementation
Advisory Council on Health Systems Development
(Advises Legislature and Governor) Funded in part by HRSA SHAP Grant
Trish Riley
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Stakeholder Engagement• Address producer concerns• Engage consumers at every
level (individual, small group, large group)• Use focus groups to reach
underserved demographics• Don’t forget providers
• Must get buy-in from Governor• Must communicate with
constituent state agencies like CHIP, Medicaid• Engage Legislature• Engage carriers in
regulator/issuer meetings
Jane Cline
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Stakeholder Strategy• Will have HIX request for
comment running concurrent to stakeholder meetings• After stakeholder meetings
will develop community of interest groups to focus on specific exchange issues• Will have focus groups to
ensure that consumer input incorporated into plan
• Continuously engage stakeholders on their own turf (quarterly/ annual meetings)• Setting up website to allow
consumers to see process behind HIX planning and research• Launching statewide
stakeholder meetings over next two months
Jane Cline
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Questions and Answers
Please submit your questions through the chat function
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
www.nashp.org
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
www.SHAPaccess.org
State-developed resources:• State-Specific Overview Analyses
• Health Reform Work Plans, Timelines, and Progress Reports
• Coordinators and Coordinating Bodies
• Fiscal Analyses
• Proposals for Federal Funding
• State Laws, Rules, and Regulations
• State Implementation Websites
Share your implementation resources with us!Send to [email protected]
Check out Priority 1 for state exchange resources! Over 50 state exchange resources from 18 states now available.
www.statereforum.org
State to State Exchange on Health Insurance Exchanges Webinar: November 22, 2010
Please feel free to contact the SHAP team with any questions.
Thank You
Anne GauthierSenior [email protected]
Kathy WitgertProgram [email protected]
Christina MillerResearch [email protected]
Sonya SchwartzProgram [email protected]
Chris CantrellResearch [email protected]