Achieving Continuity of Coverage in the Exchange Commonwealth Fund Alliance for Health Reform May 20, 2011

Achieving Continuity of Coverage in the Exchange | May 20, Agenda Eligibility and Enrollment Coverage Options Health Plan Contracting, Standards and Requirements Benefits Design Basic Health Program

Achieving Continuity of Coverage in the Exchange | May 20, Continuity in Eligibility & Enrollment * Data sharing for the purposes of determining eligibility for additional benefits. Responsibility Health Benefit Exchange Medicaid / CHIP Health Benefit Exchange Individual Plan Social Services Notice to Consumer Notice and Data Transmission To Health Plan Data Sharing* Function Application enters exchange Data collected to support application (i.e., citizenship, residency, income) System screens based on data and determines subsidy level Consumer is notified of his/her subsidy level Based on subsidy level, consumer is directed towards a selection of plans If Medicaid/CHIP, consumer is further directed Consumer chooses plan Consumer is notified that selection has been received Selected health plan receives enrollment data Consumer is enrolled and coverage is activated

Achieving Continuity of Coverage in the Exchange | May 20, Coverage Options in the Exchange  State Health Subsidy Programs in ACA Medicaid for individuals < 139% FPL CHIP for children in families between 139% FPL and state ceiling Basic Health Program for individuals between 139% and 200% FPL (optional) Qualified Health Plans (QHPs) offering products for individuals with incomes between 139% and 400% FPL  QHPs offering non-subsidized products

Achieving Continuity of Coverage in the Exchange | May 20, Continuity of Coverage in the Exchange Minimal Integration Maximum Integration Strategies  Contracted Plans  Marketing Rules  Quality Strategies  Reporting Requirements  Benefits  Provider Networks  Basic Health Program Goals  Facilitating transitions  Leveraging buying power

Achieving Continuity of Coverage in the Exchange | May 20, Contracting Options MMC / BHPBHP / QHP MMC / BHP / QHP Medicaid Managed Care/Basic Health Program Basic Health Program/Qualified Health Plan

Achieving Continuity of Coverage in the Exchange | May 20, Certification Requirements Across Plans Federal Standards for QHPs State Standards for MMC Plans State Standards for Commercial Plans Federal Standards for QHP Certification  Licensed insurer  Provides essential benefit package  Charges same premium in and out of Exchange  Network ensures sufficient choice of providers  Inclusion of “essential community providers”  Accreditation on clinical quality measures  Provision of information on quality measures  Implementation of QI strategies  Utilization of a standard format for presentation of benefits  Utilization of a uniform enrollment form  Marketing requirements

Achieving Continuity of Coverage in the Exchange | May 20, Quality Strategies Across Plans Federal Standards for QHPs  Increased reimbursement or other incentives for and reporting of Implementing activities to improve health outcomes, including use of medical homes Implementing activities to prevent readmissions Implementing activities to improve patient safety and reduce medical errors Promotion of wellness and health Reduction of disparities  As of Jan. 2015, a QHP may only contract with a hospital that Utilizes a patient safety evaluation system Assures patients receive comprehensive plan for hospital discharge Implements a health care QI program Federal Standards for QHPs State Standards for MMC Plans State Standards for Commercial Plans

Achieving Continuity of Coverage in the Exchange | May 20, Consumer Information and Reporting Requirements Federal Standards for QHPs  Provide information in plain language on: Claims payment policies Periodic financial disclosures Data on enrollment and disenrollment Data on denied claims Data on rating policies Information on cost sharing Information on enrollee rights Federal Standards for QHPs State Standards for MMC Plans State Standards for Commercial Plans

Achieving Continuity of Coverage in the Exchange | May 20, Essential Benefits Minimum Benchmark Maximum Benchmark* Standard Medicaid Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services Prescription drugs Rehabilitative and habilitative services Laboratory services Preventive and wellness services Pediatric services incl. oral and vision care EPSDT Family planning Non-emergency medical transportation FQHC / Rural Health Center services Nursing facility services or equivalent institution Home or community-based services * Subject to HHS approval ** Optional Benefit Options **

Achieving Continuity of Coverage in the Exchange | May 20, BHP: An Affordable Bridge Between Medicaid & QHP?  Citizens and lawful immigrants with incomes between 139% and 200% of FPL who would otherwise access coverage through Exchange.  Lawful immigrants with incomes < 139% of FPL who are not eligible for Medicaid  States must undertake procurement  States receive 95% of federal premium subsidies plus offset for out-of-pocket (OOP)  Premiums paid by enrollee cannot cost more than the second lowest-cost silver plan, with OOP at or below platinum or gold levels.  BHP eligible individuals cannot purchase QHPs

Achieving Continuity of Coverage in the Exchange | May 20, For More Information Deborah Bachrach Special Counsel Manatt, Phelps & Phillips, LLP 7 Times Square New York, New York (212)