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Health Benefit Exchange Update Kelly Smith – Director, SHOP Exchange Sherry Tomasky - Director, Stakeholder Engagement Northeast NAHU Presentation June.

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Presentation on theme: "Health Benefit Exchange Update Kelly Smith – Director, SHOP Exchange Sherry Tomasky - Director, Stakeholder Engagement Northeast NAHU Presentation June."— Presentation transcript:

1 Health Benefit Exchange Update Kelly Smith – Director, SHOP Exchange Sherry Tomasky - Director, Stakeholder Engagement Northeast NAHU Presentation June 13,

2 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 Contracted with customer service organization Invited Health Plans to participate in the Exchange Invited organizations to apply to be In-Person Assistors/Navigators, created a complete broker training curriculum Received conditional certification from HHS in December

3 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 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 3

4 Certification SHOP End-to-End Flow and Online Experience Create NY-HBE Account Build Company Information Agree to Terms of Participation Receive NY HBE Certification Pre-Certification Training/ Application Pre-select Plans Resolve Problems in Customer Support Select Coverage Plan(s) Process Appeal Enrollment / Other Processing Send Enrollment to QHP Identity Proofing Print and Mail Notices Broker or Agent Build Companies and Rosters Enter Company Information Enter Company Roster Information Plan Selection Attend DFS NY HBE Training Pass Exam Mail Customer Support In-Person Assistor / (Broker or Navigator) Employer Phone Broker or Agent Employer Online Employees receive an invitation from NY HIX to log on and create an account – flow not depicted here

5 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 5

6 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 Must offer 1 Standard Plan at ever metal level, in each county of the service area Must cover Essential Health Benefits package Cost Sharing for Standard Plans 6

7 1.Ambulatory patient services 2.Emergency room services 3.Hospitalization 4.Maternity and newborn care 5.Mental health and substance abuse disorders 6.Prescription drugs 7.Rehabilitation and habilitation services and devices 8.Laboratory services 9.Preventive and wellness services and chronic disease management 10.Pediatric services, including oral and vision 77

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9 May offer up to 3 Non-Standard Plans Cannot offer fewer benefits than Standard Plans May offer additional benefits Can use different networks and different cost sharing, but must be AV equivalent Can make AV equivalent benefit substitutions for Preventative/Wellness/Chronic Disease Management or for Rehabilitation/Habilitation 9

10 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 were due May 15 th Anticipated notification of Certification is July 15,

11 Exchange training will be CE credit eligible SHOP Training – 8 credits Individual Exchange Training – 8 credits Timeline: SHOP training classes begin early August and continue through Individual Exchange training for brokers will be available in late August/September. Certification testing immediately follows completion of training. Training format : Classroom, online, webinar. Brokers will be notified of rollout via Exchange website, , through state associations, and on future Exchange webinars starting in July Broker Training and Certification

12 Verification Create NY-HX Account Create Application / Demographics Build Household / Income Apply for Exemption Verify at Federal Hub Verify Through NYS Interfaces Application / Account Management Display Eligibility Results Resolve Problems in Customer Support Select Coverage Plan(s) Process Appeal Enrollment / Other Processing Send Enrollment to QHP Send Enrollment to Medicaid / CHIP Apply for Coverage Mail Online Customer Support In-Person Assistor / (Broker or Navigator) Apply for Assistance Print and Mail Notices Individual, or Authorized Representative Eligibility Determination Apply MAGI Rules Apply Program Specific / Special Rules Plan Selection Phone

13 Source: Kaiser Family Foundation Subsidy Calculator Income% FPLAnnual Tax Credit Estimated Monthly Premium Single$28,000243%$2,318$182 Single$40,000348%$700$317 Family of 4 (1 parent, 3 Children) $50,000213%$2,845$138 adult $27 Child Health Plus for 3 kids Illustration of Tax Credits for Individuals

14 Online – Through the Exchange portal for new applications and administrative renewals – Web chat for assistance In Person – In Person Assistors and Navigators – Agents and Brokers – Informal Assistors – Assistance available in many languages Phone – Leverage current public program call center – Assistance available in most languages Mail – Upon request 14

15 Conduct community outreach/Complete Applications Compensation from DOH grant program 5-day training and certification required Serve Individuals and SHOP IPA/Navigators Conduct community outreach/Complete Applications No compensation from Exchange 5-day training and certification required *Pending further federal guidance Certified Application Counselors* Complete Applications Commission-based compensation Training and certification required Choose to certify in SHOP, Individual, or both Insurance Brokers/Agents 15

16 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,

17 Navigator RFA Issued Navigator RFA submission deadline RFA Review period Navigator awards announced Open Enrollment WE ARE HERE 17

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20 Contacts: Kelly Smith Director, SHOP Exchange Sherry Tomasky Director, Stakeholder Engagement 20


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