1. Health Care Reform and NonProfits: A New Prescription
Maryland Health Connection Update
May 21, 2013

2. Background on Maryland Health Benefit Exchange
Today’s Agenda
Background on Maryland Health Benefit Exchange
Maryland Health Connection
Individuals & Families
Small Business Health Options Program (SHOP)
Consumer Assistance
Consumer Plan Choice
Access to Care
Implementation Update
Ways to Get More Information

3. Background

4. Overview of Maryland Health Connection
The Patient Protection and Affordable Care Act requires each state to establish a “health insurance exchange” by 2014
A marketplace where individuals and small businesses explore, compare and enroll in health insurance and public assistance programs as well as access federal tax credits and cost-sharing subsidies
States had a choice to establish a state-based exchange, join a partnership or the federally-facilitated exchange; Maryland opted to establish a state-based health insurance exchange
Maryland’s exchange is called Maryland Health Connection

5. Why It’s Important to Maryland
Expands access to health insurance for 730,000 Marylanders (13% of Maryland) currently without health insurance
Gives individuals access to primary care physicians, preventive services
Provides federal subsidies for individuals up to 400% of FPL to pay for health insurance premiums
Infuses $600 million in federal subsidies into the State of Maryland by 2015  NEW funds in health care system
Lowers uncompensated care costs in the healthcare system

6. Maryland Health Connection – a service of the Maryland Health Benefit Exchange

7. Maryland Health Connection – Individual Marketplace
One single entry point for commercial insurance or Medicaid
Offers tax subsidies and cost sharing reductions to individuals and families
Only place individuals can access subsidies
Federal government will pay a portion of costs for health insurance for people who earn up to 400% of FPL
Cost sharing reductions are available to individuals under 250% of FPL
Open Enrollment Period Begins: Oct. 2013
Coverage Effective: Jan. 2014

8. Individual Marketplace: Enrollment Flow
Application
Eligibility Determination
Tax Credit Eligibility
Plan Shopping
Initial Payment
Collection
Confirmed
Coverage
Notify Carriers
Consumer completes online application for insurance coverage. Streamlined application to allow for a “no wrong door” approach.
Consumer is able to make the initial premium payment directly through Maryland Health Connection.
Maryland Health Connection will display a message to the consumer for coverage start date.
If not eligible for Medicaid, Consumer is evaluated and notified of eligibility for tax credits.
Maryland Health Connection will send a file to carrier (s) to notify them of enrollment information and of premiums collected
Consumer is able to select from available plans based on personal preferences.
Individual Exchange Administration
Initial Premium billing
Carrier payment
On-going eligibility / enrollment management
Enrollment and funds flow reconciliation

9. Individuals & Families Subsidies
Single Person
FPL %
Annual
Income
Maximum Premium
(as % of Income)
Enrollee Monthly Share
133% FPL
$ 14,856.10
2.00% $
150% FPL
$ 16,755.00
4.00% $
200% FPL
$ 22,340.00
6.30% $
250% FPL
$ 27,925.00
8.05% $
300% FPL
$ 33,510.00
9.50% $
350% FPL
$ 39,095.00 $
400% FPL
$ 44,680.00 $

10. Maryland Health Connection – SHOP Marketplace
Maryland Health Connection will have a Small Business Health Options Program (SHOP) dedicated portal for small businesses and their employees
Small businesses (including non-profits) with up to 50 employees may participate
In 2016, the ACA modifies the definition of small group to 100 employees
Small businesses can offer coverage to employees in two ways (one of which is new to the market)
Employer Choice / Employee Choice
Tax credits available for first two years

11. SHOP Marketplace: Enrollment Flow
Eligibility Determination
Employer Plan Set-up
Estimated Quote
Employee Enrollment
Validate Group
Notify Carriers
Employees make plan selections with information on employer contribution and their expected cost
Validate that all requirements for the employer (e.g. minimum participation, creditable coverage for employees) have been met
Notify carriers to contract with employer and start coverage for employees
Employer is evaluated for eligibility to purchase from SHOP based on demographic information.
Employer selects a metal level (Employee Choice) or a carrier (Employer Choice) and sets defined contribution amount.
SHOP provides an estimated quote based on employer choices and employee census (age, income, etc.)
SHOP Administration
Premium aggregation and billing
Carrier payment
On-going eligibility / enrollment management (employee adds, deletes, life changes, etc.)
Enrollment and funds flow reconciliation

12. Consumer Assistance Program

13. Projected New Enrollment
SHOP
New Medicaid
Individuals/Families on
Maryland Health Connection

14. Consumer Assistance Program
Multiple resources will be available for consumers who need assistance with understanding insurance options.
Online at
Shop & Compare Options
Enroll
In-person Assistance:
Connector Program
Navigators
Assisters
Application Counselors
Insurance Producers (Brokers/Agents)
Captive Producers
Consolidated Services Center (call center)
Customer service
Application and enrollment assistance
Language line/ translation services
TTY for the hearing impaired
Access to Coverage

15. Overview of the Connector Program
Formerly called the Navigator Program
The Connector Program has two components
Navigator Program: made up of Certified Individual Navigators and Licensed SHOP Navigators
In Person Assistance Program: made up of Assisters who will perform Outreach and Education duties and facilitate eligibility determinations and Non-certified personnel who will provide support services
Insurance producers will have the option to be authorized to sell through the exchange, and will be trained on advanced premium tax credits, cost sharing subsidies, and other assistance options
MHBE has awarded six Connector Entities in six distinct geographic regions to implement the Connector Program in their regions

17. Consumer Assistance Roles
Navigators will:
Conduct public education and outreach as required by the Affordable Care Act
Distribute fair and impartial information
Facilitate enrollment in health plans
Provide referrals for grievances, complaints and questions
Provide information in a culturally and linguistically appropriate manner
Maintain expertise in eligibility, enrollment and program specifications
Refer insured small groups and individuals back to producers
Assisters will:
Conduct public education and outreach;
Facilitate eligibility determination for subsidies, Medicaid, and MCHP;
Facilitate and provide ongoing support

18. Consumer Assistance Roles
Application Counselors:
New role introduced by U.S. HHS to allow for additional resources to assist
Facilitate enrollment in health plans
Act in the best interest of the enrollee
Disclose any potential conflicts
Receive no funding from the MHBE
Insurance Producers (Agents/Brokers):
Serve an important role in the Exchange
Continue to work directly with small group customers
Register to become authorized to sell QHP inside the Exchange
Be compensated directly by the carriers (as they currently are)
Receive training from the Exchange

19. Consumer Assistance Roles
Captive producers:
may transition carrier’s existing enrollees into Maryland Health Connection qualified plan, and may provide enrollment assistance to individuals who contact the carrier;
must act in best interests of consumer;
must disclose their employment with carrier;
are subject to same restrictions as navigators; and
are subject to same licensing and MHBE authorization requirements as authorized producers;
Carriers must:
document and retain records of such disclosures for three years;
provide disclosure records and updated lists of captive producers to Exchange;
Non-compliance with requirements is grounds for sanctions for both captive producer and carrier;
Program must be administered in non-discriminatory manner without adverse selection impact; and
Program to be sunset after three years, with study and report in 2015 on its effect and whether or not it should be continued.

20. Consumer Assistance Roles
Consolidate Service Center:
Inbound Call Center (Toll-Free Hotline) linked from
Language Line/Translation Services
TTY (Hearing Impaired)
Extended Hours During Open Enrollment
Coordination with Insurance Carriers and Connector Entities
Scheduled Opening: August 2013 (with launch of advertising campaign and social media launch)

21. Consumer Plan Choice

22. Plan Management Guiding Principles
Maryland Health Connection will include a variety of carriers and benefit plans designed to meet the insurance needs of consumers.
Carriers must be “authorized” and their plans must be “certified” to ensure compliance with ACA requirements
The following guiding principles have been used to manage plans that will be offered on Maryland Health Connection:
Promote affordability for the consumer and small employer
Ensure access to quality care for consumers presenting with a range of health statuses and conditions
Facilitate informed choice of health plans and providers by consumers and small employers
Reduce health disparities and foster health equity

23. Medical Authorized Carriers Stand-Alone Dental
Maryland has adopted a strategy for that allows any willing carrier to offer qualified health plans on Maryland Health Connection as long as they meet federal and state requirements. This approach will foster competition in the marketplace and help to build stability for Maryland Health Connection.
Medical
Aetna
CareFirst
Coventry
Evergreen (CO-OP)
Kaiser
United HealthCare
Stand-Alone Dental
Aetna Dental
BEST Life
Delta Dental
DentaQuest
Dominion Dental
Guardian
Metropolitan Life
United Concordia

24. Product Summary
Plans offered on Maryland Health Connection will include:
Medical Only Plans
Medical Plans with Embedded Dental
Stand-Alone Dental Plans
Carriers are required to obtain approval from the MIA on plans before they can be certified by MHBE.
Carrier applications indicate that they intend to offer PPO, HMO, EPO, POS products.
Additionally, carriers have noted that they intend to offer plans across all metal tiers for the Individual and SHOP marketplaces.
Essential Health Benefits
Ambulatory Services
Emergency Services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services including oral and vision care

25. Carrier Participation Update
Multi-State Plan Program
Section 1334 of the Affordable Care Act directs the U.S. Office of Personnel Management (OPM) to contract with private health insurance issuers to offer at least 2 multi-state plans to individuals and small business in each state.
MHBE and MIA are working with OPM to develop procedures for authorizing multi-state plan issuers and certifying their plans.
It is expected that Maryland will have at least one multi-state plan issuer in year 1.

26. Facilitating Plan Selection
Plan Quality Program
Facilitating Plan Selection
As newly eligible consumers enter the health insurance market, the Maryland Health Connection portal will include several decision support tools to assist consumers in understanding insurance choices
Provider search
Ranking by premium
Metal level search
Carrier search
Plan Quality Star Rating System
Maryland Health Connection Quality Report

27. Star Rating System Plan Quality Program
Plan quality star rating scores will be based on a compilation of information from the following tools:
Healthcare Effectiveness Data and Information Set (HEDIS)
Consumer Assessment of Health care Providers and Systems (CAHPS)
Maryland Behavioral Health Assessment (BHA)
Maryland Health Plan Quality Profile (QP)
Maryland Race/Ethnicity, Language, Interpreters, and Cultural Competency (RELICC)

28. Access to Care

29. Exchange Board of Trustees Statement of Policy
Maryland Health Connection intends to offer insurance plans that provide meaningful access to a full range of critical health services, including primary care, reproductive health care, care for patients with HIV/AIDS, and behavioral health care.
Services will be made available via:
Traditional network providers
Essential Community Providers
Carriers will be allowed to self-define network composition but will be required to include a diverse array of providers to ensure access to care is available.

30. Access to Care Program
The State has developed the “Access to Care Program” jointly with DHMH, MHBE, and CHRC.
Goals:
Promote robust participation of safety net providers in health plans certified and sold on MHBE;
Promote sustainability of safety net providers as many transition from a grant-based system of revenue to billing third-party payors; and
Encourage safety net providers to contract with Medicaid MCOs and commercial carriers.

31. Access to Care – Planning & Oversight
Plan Certification Preparation
Q1 2013
Supply & Demand Data
Access to Care Consultation Sessions
Access Plan Templates
Safety Net Provider Planning
Q1 – Q4 2013
Access to Care Regional Forums
Safety Net Provider Readiness Services
Ongoing Oversight & Monitoring
2014
Consumer Advisory Committee
Provider Advisory Committee
Quarterly and Annual Reporting

32. Safety Net Provider Planning
Access to Care Regional Forums
MHBE has partnered with the DHMH and CHRC to host regional “meet and greet” sessions to allow participating insurance carriers and safety net providers to begin discussions on contracting
Information on expected enrollment
Information on Medicaid & Commercial Carrier requirements
Technical assistance overview

33. Access to Care Regional Forums
There will be six forums in June intended for healthcare providers and insurance carriers:
Southern Maryland: June 6, 10:00 am to 12 noon; Waldorf Jaycees Community Center, Militia Room
Eastern Shore: June 10, 1:00 pm to 3:00 pm, Chesapeake College, Todd Performing Arts Center
Central Maryland: June 12, 10:00 am to 12 noon, Howard County Health Department
Western Maryland: June 18, 1:00 pm to 3:00 pm, Venice (Best Western) Hotel, Ballroom
Washington Metro region: June 20, 10:00 am to 12 noon, Silver Spring Civic Building
Baltimore Metro region: June 25, 10:00 am to 12 noon, UMBC Tech Center 33

34. Safety Net Provider Planning
Technical Assistance Program
In consultation with the MHBE and DHMH, the CHRC is planning to support a technical assistance program to build capacity and promote readiness of safety net providers.
The assistance will be geared towards helping safety net providers transition from a grant-based revenue structure to one that involves billing third-party payors (Medicaid/MCO and commercial carriers).
The CHRC may also provide opportunities for grant-funding to support infrastructure development later this year.
Technical Assistance
Contracting with QHPs & Medicaid MCOs
Credentialing
EMR/Billing

35. Implementation Update

36. What’s Next?
Federal Certification: Maryland Received Conditional Certification on December 10, 2012
Continued development of IT system
Outreach & Education: Q2 2013
Training: Starting August 2013
Consolidated Services Center (Call Center): August 2013
Individual Open Enrollment: Begins October 1, March 31, 2014
SHOP Begins: January 1, 2014 then based on renewal date

37. Ways to Get Involved Now!

38. Online Resources MarylandHealthConnection.gov MarylandHBE.com
Sign Up for weekly newsletter
Sign Up for Text Updates: Text “Connected” to 69302
Get information on resources available to help find insurance now
Enroll in plans starting October 1, 2013
MarylandHBE.com
Meeting Information
RFP Announcements
Job Information

39. Thank you!
For questions on the information contained in this presentation, please contact: Tequila Terry Director, Plan & Partner Management Maryland Health Benefit Exchange