2019 ohio product launch & agent...
TRANSCRIPT
2019 OhioProduct Launch & Agent Training
Kahassai Tafese (KT)Broker Channel Manager – Eastern Region (Ohio, Michigan, Wisconsin)[email protected] Cell
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The Molina Mission
Our Vision
Our Mission
We envision a future where everyone receivesquality health care.
To provide quality health care to persons receivinggovernment assistance.
Caring Enthusiastic Respectful Focused
Thrifty Accountable Feedback One Molina
Core Values
What We Do
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We Are Here to Stay!!
#156 on the Fortune 500 List
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Molina For Marketplace 2019
Molina is selling on-exchange products in 9 states:1. California2. Florida3. Michigan4. New Mexico5. Ohio6. Texas7. Washington8. Wisconsin9. Utah
Serve our members and support our agents
as we prepare for future growth.
2018: We’re fixing the plane while in flight!
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Core Ops
Cost of Care
Care Delivery
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“In order to RISE
from its own ashes,
a Phoenix first must
Burn.”
09/17/2018
Stock Performance
5 years ago Molina’s stock was trading at $36
1 year ago Molina’s stock was trading at $62
6 months ago Molina’s stock was trading at $77
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• 2014 – 2,032
• 2015 – 5,937, 292% growth
• 2016 – 15,244, 257% growth
• 2017 – 26,647, 174% growth
• 2018 – 15,117, -43% growth
• 2019 -
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Effectuated Marketplace Membership
Year Total
2014 (December) 14,675
2015 (December) 207,734
2016 (April) 649,663
2017 (January) 1,025,122
2018 (January) 456,111
2019 (January)
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Source Cumulative Broker Enrollment Stats 2017 Slide Updated 1.27.2017
48%
64%
34%
27%
41%
25%
42%
47%
*UT-57%, WI-39%
Marketplace Product
Strategy 2019
All States
V.15
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Molina Marketplace Product Strategy - 2019
• Product Portfolio –
Renewing – Molina Marketplace Product in all States
Discontinuing –
Molina Options Product (CMS Standard Plans) – TX, OH, MI, FL
Molina Options Members will be mapped to matching Molina Bronze or Silver upon renewal
Molina FFM Bronze plans – OH, MI
Bronze Members will be mapped to Silver 250 per regulation, upon renewal
Plan Design Positioning
Maintain one FFM standard plan portfolio for all FFM states Competitive research by state, indicated no imperative for market specific plans.
Agreement by state Health Plans
SBM States: WA – Continue to use FFM Silver and Gold standard portfolio
CA – Continue to apply Covered CA portfolio by contract
Plan cost share changes 2019 AV calculator is forcing higher cost share; adjusted plan deductibles/maximum out
of pocket/cost shares to meet AV targets
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Molina Marketplace Product Strategy - 2019
• Service Area Planning
Renewing in Existing Counties/Rating Areas – CA, FL, MI, NM, TX, WA
Marketplace Service Area Expansion – OH
o New counties: Champaign, Clinton, Fayette, Highland, Huron,
Muskingham, Pickaway, Pike
Marketplace Re-entry – UT, WI
o UT Service Area: Weber, Davis, Utah, Salt Lake (pending network
negotiations: Washington, Cache, Summit, Tooele, Iron)
o WI Service Area: Milwaukee, Racine, Kenosha, Washington,
Ozaukee, Waukesha, Brown
• Pricing
2019 pricing will again account for premiums without CSR funding
2018 Federal regulation supporting stabilization did not pass to fund CSRs
“Silver-loading” in all states; will increase 2nd lowest Silver plan premiums
and premium subsidies
Pricing elasticity – actuarial team calculated rate and corresponding
membership impact to find the target rate for optimal profits.
Molina Marketplace Product Strategy - 2019
• Product Portfolio (continued) –
Plan Cost Share Revisions
Completed competitive analysis and recommendations for cost share
changes to steer usage towards the appropriate level of care and improve
plan performance, in three key service categories:
Product Design Changes: Final Recommendations and Rationale
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1 Emergency Services – Move from copay to coinsurance after plan deductible as applicable Rationale – Financial disincentive for ER use, parity against competitors, selection avoidance
Reduce Barriers to Urgent Care – reduced cost share; more than PCP office visit, but less than Specialist office visit and ER Rationale – Incents Urgent Care over ER, avoids Specialty use
Prescription Drugs –
Separate Rx deductible for Silver 200 & 250 plans – Reversion back to 2018 positioning Rationale - Provides limited financial steerage on use, but retains access, allowing high risk
members to obtain drugs supporting Rx data for Risk Adjustment
Revised Rx Tier Definitions – Market parity, flexibility & performance Rationale - Revised Rx Tier definitions address financial performance, allowing formulary
flexibility by placing drugs within tiers by cost
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2019 Marketplace Plan Design SummaryLegend:
• Benefit reduction from 2018 highlighted in Red
• Benefit increase from 2018 highlighted in Green
• Description change - Blue
▲ Plan deductible Applies
2019 MarketplaceAll FFM States
Bronze Silver 100 Silver 150 Silver 200 Silver 250 Gold
AV (2019 calculator) 63.00% 94.82% 87.58% 73.79% 68.35% 78.91%ACCUMULATORS
Medical Deductible, Individual $6,400Combined Med/Rx
N/A $750 $3,300 $5,350 $2,925
Rx Deductible, IndividualIncluded in
Medical deductibleN/A N/A
$400(Ded applies to Tiers 3
& 4)
$400(Ded applies to Tiers 3
& 4)N/A
OOPM, Individual $7,900 $1,400 $2,600 $6,300 $7,900 $5,000
EMERGENCY/URGENT SERVICES
Emergency Room - Applies to facility charges only— Waived if admitted (Inpatient cost-sharing applies)
40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Urgent Care $75 $10 $20 $50 $50 $35
OUTPATIENT PROFESSIONAL/FACILITY SERVICES Office Visit — Primary Care $35 $0 $10 $20 $30 $10
Office Visit — Specialty Care $80 (after ded) ▲ $15 $30 $60 $75 $50
Outpatient Professional & Facility— OP Surgery— OP Non-Surgical Services
40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
Specialized Scanning Services (CT/PET Scan, MRI) 40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
INPATIENT HOSPITAL SERVICESMedical / Surgical — Professional & Facility
40% (after ded) ▲ 10% 20% (after ded) ▲ 30% (after ded) ▲ 30% (after ded) ▲ 20% (after ded) ▲
PRESCRIPTION DRUGS §
Tier 1 - Lower-Cost Generic and Brand Name Drugs $20 $2 $5 $10 $20 $10
Tier 2 – Preferred Generic and Brand Name Drugs 40% (after ded) ▲ $15 $30 $60 $60 $50
Tier 3 – Non-Preferred Brand Name Drugs 50% (after ded) ▲ 20% 30% 40% (after Rx ded) ▲ 40% (after Rx ded) ▲ 30%
Tier 4 – Generic and Brand Name Specialty Drugs 50% (after ded) ▲ 20% 30% 40% (after Rx ded) ▲ 40% (after Rx ded) ▲ 30%
Tier 5 – Preventive Drugs No Charge No Charge No Charge No Charge No Charge No Charge
Cost Share Changes by Metal Plan Note: FFM Portfolio (no Bronze Plan offering) applies to WA, MI, OH, and market reentry in UT & WI
Perspective Check
What is the story with Bronze?
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Silver Bronze
Premium $500 $450
Claims $350 $178
Risk Transfer $50 $200
Admin $90 $81
Net Income $10 -$9
• Premium is low
• Claims are low
• Risk Transfer is the breaking point
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2019 Product ChangesFederal Requirements and Molina EOC Revisions
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Molina Marketplace Product Strategy - 2019
Product Changes: Regulatory Requirements
ACA Product Revisions Regulatory Impact
Operational Impact
Open Enrollment• FFM States
• November 1, 2018 through December 15, 2018
• State based Marketplaces-• WA – November 1, 2018 through December 15, 2018• CA -- October 15, 2018 through January 15, 2018
Yes –• CMS
Templates
Yes –• EP&B• Web Site• Network Data• Renewal
Communication• Contact Center• Sales and
Distribution• Configuration
Increased Maximum Out of Pocket Amounts Yes –• CMS
Templates• EOC• Schedule
of Benefits
• SBC
Yes –• QNXT
Configuration• Web Site• Marketing• Configuration
2018 2019 2019 Silver CSR Maximums
Individual $7,350
Individual $7,900
100 – 150% AV Plan
$2,600 / $5,200
2X Family $14,700
2X Family $15,800
150 – 200% AV Plan
$2,600 / $5,200
200 – 250% A V Plan
$6,300 / $12,600
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Molina Marketplace Product Strategy - 2019
Product Changes: Molina EOC Revisions
Molina EOC Revisions Regulatory Impacts
Operational Impacts
Prescription Drug Tier Definition Revisions, Are Intended To:• Address better financial performance with drug tiering based upon cost • Allow the flexibility for generic and/or brand drug placement within the appropriate
drug tier • Better align EOC language and ensure that member cost share corresponds to drug
efficacy, cost and administration, regardless of generic/brand/specialty drug types • Bring Molina into parity with other ACA Issuers, mitigating adverse selection risk
Yes -• EOC• SBC• ID cards• Member
materials
Yes –• Member
Portal• IT• Contact
Center
2018 – Pharmacy Tier Naming 2019 – Pharmacy Tier Naming
EOC – Same definitions 2014-18 EOC - Modified Tier Definitions will track to:
EOC and SBCTier-1 Formulary Generic DrugsTier-2 Formulary Preferred Brand Name DrugsTier-3 Formulary Non-Preferred Brand Name DrugsTier-4 Formulary Specialty (oral and injectable) Drugs Tier-5 Formulary Preventive Drugs
EOC and SBC:Tier-1: Lower-Cost Generic and Brand Name DrugsTier-2: Preferred Generic and Brand Name DrugsTier-3: Non-Preferred Brand Name DrugsTier-4: Generic and Brand Name Specialty DrugsTier-5: Preventive Drugs
ID Cards:Prescription Drugs:• Generic Drugs• Preferred Brand Drugs• Non-Preferred Brand Drugs• Specialty Drugs
ID Card: Prescription drugs -• Tier-1 • Tier-2 • Tier-3 • Tier-4
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Molina Marketplace Product Strategy - 2019
Product Changes: Molina EOC Revisions
Molina EOC Revisions Regulatory Impacts
Operational Impacts
Section: Definitions, and changes as needed throughout Description of Change: Added “Allowed Amount” definition to clarify Molina’s maximum coverage
amount for emergent and non-emergent services, obtained from par or non-par providers. Legal approved language below:
“Allowed Amount“ - Allowed Amount means the maximum amount that Molina will pay for a Covered Service less any required Member Cost Sharing.
Services obtained from a Participating Provider: This means the contracted rate for such Covered Services.
Emergency Services and emergency transportation services from a Non-Participating Provider: Unless otherwise required by law or as agreed to between the Non-Participating Provider and Molina, the Allowed Amount shall be the greatest of 1) Molina’s median contracted rate for such service(s), 2) 100% of the published Medicare rate for such service(s), or 3) Molina’s usual and customary method for determining payment for such service(s).
All other Covered Services received from a Non-Participating Provider in accordance with this Agreement: This means the lesser of Molina’s median contracted rate for such service(s), 100% of the published Medicare rate for such service(s), Molina’s usual and customary rate for such service(s), or a negotiated amount agreed to by the Non-Participating Provider and Molina.
Yes -• EOC• Legal
Yes –• No
New EOC language highlighted in Red
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Molina Marketplace Product Strategy - 2019
Product Changes: Molina EOC Revisions
Molina EOC Revisions Regulatory Impacts
Operational Impacts
Section: Outpatient Hospital/Facility Services, Laboratory Tests Description of Change: Revise description of laboratory tests to clarify that non-par lab
services are not coveredWe cover the following services when Medically Necessary. These services are subject to Cost Sharing. You must receive these services from Participating Providers. Otherwise, the services are not covered, You will be 100% responsible for payment, and the payments will not apply to Your Deductible or Your Annual Out-of-Pocket Maximum.
Yes -• EOC
No
Section: Outpatient Hospital/Facility Services, Specialized Scanning Services Description of Change: Revise description of specialized scanning services to allow health
plans the flexibility to steer towards lower cost outpatient facilitiesWe cover specialized scanning services to include CT Scan, PET Scan and MRI by Participating Providers. Separate Cost Sharing may apply for Professional services and Facility services. Prior Authorization is required. Hospital locations are covered for Emergency Services, observation stay, or during an inpatient hospital admission. Molina will help you select an appropriate facility.
Yes -• EOC
Yes –• UM
Section: Exclusions Description of Change: Add/Update language for the following services
• Add -- Gene Therapy: Molina does not cover gene therapy.• Revise to align with state coverage requirements -- Dietician: A service of a
dietician is not a covered benefit. This exclusion does not apply to services under “Hospice Care” or for Covered Services described in the section titled, “Phenylketonuria (PKU) and Other Inborn Errors of Metabolism”.
Yes -• EOC
No
New EOC language highlighted in Red
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Molina Marketplace Product Strategy - 2019
Product Changes: Molina EOC Revisions
Molina EOC Revisions Regulatory Impacts
Operational Impacts
Section: Schedule of Benefits Description of Change: Revise to clarify member cost share for covered services received
in the home settingSeparate cost share may apply for other covered benefits delivered in the home setting (e.g., injectable drugs, durable medical equipment, etc.)
Yes -• EOC
No
Section: Schedule of Benefits and Prescription Drug Sections Description of Change: Clarified language to include all types of cost-sharing reduction
programs.Please note, Cost Sharing reduction for any prescription drugs obtained by You through the use of a discount card or coupon provided by a prescription drug manufacturer, or any other form of prescription drug third party cost-sharing assistance, will not apply toward any Deductible, or the Annual Out-of-Pocket Maximum under Your Plan
Yes• EOC
No
Section: Summary of Benefits, Inpatient and Outpatient Services Sections Description of Change: Updated language to apply coinsurance to all medically covered
drugs, regardless of place of service (not outpatient drugs obtained through a network pharmacy)
Chemotherapy and Other Provider-Administered DrugsWe cover chemotherapy and other provider-administered drugs when furnished by Participating Providers and Medically Necessary. Chemotherapy and other provider-administered drugs, whether administered in a physician’s office, an outpatient or an inpatient setting, are subject to either outpatient facility or inpatient facility cost sharing.
Yes• EOC
Yes• CIM
New EOC language highlighted in Red
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Molina Marketplace Product Strategy - 2019
Product Changes: Molina EOC Revisions
Molina EOC Revisions Regulatory Impacts
Operational Impacts
Section: What is a Prior Authorization (PA)? Description of Change: Updated PA section to align with PA guidelines effective
1/1/2019; guidelines vary by statePlease note: more PA stringent requirements cannot be implemented for Marketplace if policies are changed after EOCs are filed and approved; easing of PA rules can be implemented mid-year
Yes• EOC
No
Section: Outpatient Professional Services, Preventive Care and Services Description of Change: Updated preventive services list reflect most recent USPTF
guidelines; states may also require coverage for additional services
Yes• EOC
Yes• CIM
Section: Health Education Description of Change: Updated to reflect the current programs/services available
through MHI and State Health Plans
Yes• EOC
Yes• Member
Portal• Marketing
Materials
Section: Definitions and changes as needed throughout Description of Change: Replace “Benefits and Coverage” definition with a revised
definition of “Covered Services;” ensure consistency throughout the document“Covered Services” refers to all the healthcare services, including supplies, and prescription drugs covered by the [Policy] and that You are entitled to receive from Molina under this [Policy].
Yes -• EOC
No
New EOC language highlighted in Red
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2019 Product ChangesState-specific EOC Changes
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Molina Marketplace Product Strategy - 2019
Product Changes: State EOC Revisions – MI
Molina EOC Revisions Regulatory Impacts
Operational Impacts
Section: External Review Process Description of Change: Update to DIFS’ External appeal information
Yes -• EOC
Yes –• Configuration• Member
Services• Appeals
Filing External Review Request
2018 2019
Timeframe Change 120 Days 127 Days
Updated URL www.Michigan.gov/difs https://difs.state.mi.us/Complaints/ExternalReview.aspx
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Molina Marketplace Product Strategy - 2019
Product Changes: State EOC Revisions – OH
Molina EOC Revisions Regulatory Impacts
Operational Impacts
Section: Prescription Drugs Description of Change: Update to the Opioid benefit to comply with state law.
Add opioid analgesics for chronic pain in the PA list.
Added Provision on Opioids to define the benefit offering in compliance with Ohio. Rev. Code § 3923.851
Yes -• EOC
Yes –• Configuration• Member
Services• Appeals
Opioid Analgesics Prescribed for Chronic Pain If You are prescribed Opioid Analgesics for Chronic Pain You must obtain a Prior Authorization prior to receiving Opioid Analgesics for Chronic Pain, except under the following circumstances:• Opioid Analgesics prescribed to a Covered Person who is a
Hospice Patient in a Hospice Care Program;• Opioid Analgesics prescribed to a Covered Person who has
been diagnosed with aTerminal Condition, but is not a Hospice Patient in a Hospice Care Program; or
• Opioid Analgesics prescribed to a Covered Person who has cancer or another condition
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APPENDIX
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Molina Marketplace Product Portfolio – 2019 Overview
Molina Marketplace Product Strategy - 2019
Product Design Changes: Final Recommendations and Rationale
State Benefit Marketplaces
State Catastrophic Bronze Silver 100 Silver 150 Silver 200 Silver 250 +Gold Platinum
Covered California CC Standard CC Standard CC Standard CC Standard CC Std
Washington HBE Not Available Not Available Molina Marketplace ChoiceMolina Marketplace
ChoiceNot Available
New Mexico Not Available Molina Marketplace Molina Marketplace Molina Marketplace Not Available
Federally Facilitated Markets
State Catastrophic Bronze Silver 100 Silver 150 Silver 200 Silver 250 +Gold Platinum
Michigan Not AvailableNot AvailableDiscontinue -
• Molina Options • Molina
MarketplaceMolina Marketplace
Discontinue - Molina Options
Molina Marketplace(Except for Holmes
County)Not Available
Ohio Not Available
Florida Not AvailableMolina Marketplace
Discontinue -• Molina Options
Texas Not Available
Molina Marketplace Consumer Choice
Molina MarketplaceConsumer Choice
Discontinue - Molina Options
Molina Marketplace Consumer Choice
Not Available
Not Avalable Molina State Mandated PlanMolina State Mandated
Plan
Wisconsin Not Available Not Available Molina Marketplace Molina Marketplace Not Available
Utah Not Available Not Available Molina Marketplace Molina Marketplace Not Available
Note: "Molina Options" is the Molina product name for the CMS Standard Bronze & Silver Plans. These plans will be discontinued effective 1/1/2019.
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Molina Marketplace Product Strategy - 2019
State Offering Type Service Area Action Plans
CA On-Exchange No changes Renewing all 5 metal level plans: Minimum Coverage, Bronze, Silver, Gold and Platinum
FL On-Exchange No changes Renewing FFM Portfolio• Bronze, Silver & Gold plansDiscontinuing:• Molina Options Bronze & Silver plans
MI On-Exchange No changes Renewing FFM Portfolio• Silver and Gold plansDiscontinuing:• Molina Options Bronze & Silver plans• FFM Bronze plan
NM On-Exchange No Changes Renewing FFM Portfolio:• Bronze, Silver, and Gold plans
OH On-Exchange County Expansion:Champaign, Clinton, Fayette, Highland, Huron, Muskingham, Pickaway, Pike
Renewing FFM Portfolio:• Silver and Gold plans (no Gold plan in Holmes County)Discontinuing:• Molina Options: Bronze & Silver plans• FFM Bronze plan
WA On-Exchange No Changes Renewing FFM Portfolio:• Silver & Gold plans only
WI On-Exchange Market Re-entry Pending: Brown, Kenosha, Milwaukee, Ozaukee, Racine, Washington, Waukesha
FFM Portfolio:• Silver and Gold plans only • No Bronze Plans
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Molina Marketplace Product Strategy - 2019
State Offering Type Service Area Action Plans
TX On-Exchange No changes Renewing:- TX Department of Insurance prerequisite Consumer Choice
offerings: Silver and Gold plansRenewing FFM Portfolio: - Molina Consumer Choice Bronze, Silver, & Gold plansDiscontinuing:• Molina Options – Silver plans
UT On-Exchange Market Re-entry Pending:• Weber, Davis, Utah, Salt
Lake, Washington, Cache, Summit, Tooele, Iron
FFM Portfolio:• Silver and Gold plans only• No Bronze Plans
2019 Ohio Health Plan
Benefits and Rates
Molina Healthcare of Ohio’s Offices
Greater Cleveland6161 Oak Tree Blvd, Independence
Ohio Headquarters3000 Corporate Exchange Drive, Columbus
Greater Cincinnati 25 Merchant Street, Springdale
Molina Marketplace
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• Molina Marketplace serves 33
counties
• New counties in 2019: Champaign,
Clinton, Fayette, Highland, Huron,
Muskingham, Pickaway, Pike
1. Ashtabula
2. Athens
3. Butler
4. Champaign
5. Clark
6. Clermont
7. Clinton
8. Coshocton
9. Cuyahoga
10. Fairfield
11. Fayette
12. Franklin
13. Greene
14. Hamilton
15. Hancock
16. Highland
17. Holmes
18. Huron
19. Lake
20. Licking
22. Lorain 23. Lucas23.Madison24. Mahoning25. Montgomery26. Muskingum27. Pickaway28. Pike 29.Ross30. Scioto31. Stark32. Trumbull33. Wood,
Molina Healthcare of Ohio
Network Operations
Online Provider Search
https://providersearch.molinahealthcare.com/
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Pharmacy Services and Prescriptions
You can find a list of our contracted pharmacies in your area here:
https://www.caremark.com/wps/myportal/PHARMACY_LOCATOR_FAST
Molina contracts our pharmacies through CVS/Caremark
Specialist Referrals
Molina does NOT require referrals for specialist visits
• Specialist DOES need to be contracted with Molina Marketplace• PCP should forward pertinent member information and findings to
the specialist when referring. • Some specialists may require referrals (however Molina does not)
*** Note – Authorizations are different than referrals
• Some procedures may need Prior Authorization • Helps make sure participating providers are utilized, and appropriate
level of care is provided to meet the member’s needs.
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Marketplace Provider Network – Hamilton County
• Mercy Health Formerly Catholic Health Partners*
• Anderson Hospital
• The Jewish Hospital
• West Hospital (merged with Mt. Airy Hospital)
• Clinics, Medical Centers and Urgent Care
• University of Cincinnati Medical Center
• Federally Qualified Health Centers (FQHC’s)
*Ohio’s largest health system
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Marketplace Provider Network – Franklin County
• OSU Wexner Medical Center
• The James Cancer Hospital
• Select Specialty Hospital Columbus, Inc.
• University Hospital East
• Regency Hospital OF Columbus
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Marketplace Provider Network – Licking County
• Licking Memorial Hospital
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Marketplace Provider Network – Hancock County
• Blanchard Valley Health System (HOSP)
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Marketplace Provider Network – Butler County
• Mercy Health
• Mercy Fairfield
• Kettering Health Network
• Fort Hamilton Hospital
• TriHealth
• McCullough-Hyde Memorial Hospital
• UC Health
• West Chester Hospital
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Marketplace Provider Network – Clermont County
• Mercy Health
• Clermont Hospital
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Marketplace Provider Network – Montgomery County
• Kettering Health
• Kettering Medical Center
• Soin Medical Center
• Grandview Medical Center
• Southview Medical Center
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Marketplace Provider Network – Greene County
• Kettering Health
• Greene Memorial Hospital (Xenia)
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Marketplace Provider Network – Ross/Scioto Counties
• ADENA Regional Medical Center
• Kings Daughter Medical Center
• Southern Ohio Medical Center
• Portsmouth City Health Department (FQHC)
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Marketplace Provider Network – Mahoning/Trumbull Counties
• Mercy Health
Humility of Mary Health Partners:
• St. Elizabeth Boardman Hospital (Mahoning)
• St. Elizabeth Youngstown Hospital (Mahoning)
• St. Joseph Warren Hospital (Trumbull)
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Marketplace Provider Network – Cuyahoga County
• MetroHealth System
• Lake Health
Formerly Lake Hospital System
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Marketplace Provider Network – Lorain County
• Mercy Allen Hospital
• Mercy Regional Medical Center
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Marketplace Provider Network – Lucas County
• Mercy Health
• Mercy St. Ann’s
• Mercy St. Charles
• Mercy St. Vincent
• University of Toledo Medical Center
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Marketplace Provider Network – Madison County
• Madison Health
• Madison Health Hospital• Madison Family Health Corp (prof group of
specialists owned by the hospital)
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Marketplace Provider Network – Fairfield County
• Fairfield Medical Center
• Fairfield Healthcare Professionals, Inc.
(employed/owned physicians)
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Marketplace Provider Network – Stark County
• Sisters of Charity Health System
• Mercy Medical Center Canton
• Mercy Professional Care Corp
(employed/owned physicians)
Renewal/Member Communication
© 2018 Molina Healthcare, Inc.
2019 Open Enrollment
California
10/1/18 – Window Shopping
10/15/18 – Open Enrollment Begins
10/31/18 – 11/21/18 - Passive Renewal
12/15/18 – Deadline to Enroll for Jan 1 Coverage
1/15/18 – Open Enrollment Ends for Feb 1 Coverage
FFM
10/16/18 – 10/27/18 - Passive Renewal
11/1/18 - Open Enrollment begins
11/3/18 – 12/15/18 – Switch files from Exchange
12/15/18 – Deadline to Enroll for Jan 1 Coverage
12/15/18 – Open Enrollment Ends
Washington
11/1/18 - Open Enrollment begins
12/15/18 – Deadline to Enroll for January 1 Coverage
12/15/18 – Open Enrollment Ends
57
© 2018 Molina Healthcare, Inc.
2019 Discontinuation and Renewal Notices
58
Mailing Schedule
Samples of Renewal, Discontinuation/Renewal (Plan Change), Discontinuation/Renewal (Product Change) Notices
Household
CountState Scenario Template ID
FTP to Merrill Date / Time of
Day
Mailing
Date
Quantity to
Per Day
Delivery
Date
Regulatory
Requirement -
Received by
Date
5,871 OH Renewal T538 10/10/2018 - Evening 10/11/2018 5,871 10/15/2018 11/1/2018 September 2018
4,779 OH Renewal (Plan Change) T817 10/10/2018 - Evening 10/11/2018 4,779 10/15/2018 11/1/2018 Su M Tu W Th F Sa
3,259 OH Renewal (Product Change) T820 10/10/2018 - Evening 10/11/2018 3,259 10/15/2018 11/1/2018 1
16,401 NM Renewal T540 10/10/2018 - Evening 10/11/2018 16,401 10/16/2018 11/1/2018 2 3 4 5 6 7 8
128,240
TX Renewal T542 10/11/2018 - Evening 10/12/2018 30,000 10/17/2018 11/1/2018 9 10 11 12 13 14 15
TX Renewal T542 10/11/2018 - Evening 10/15/2018 30,000 10/19/2018 11/1/2018 16 17 18 19 20 21 22
TX Renewal T542 10/11/2018 - Evening 10/16/2018 30,000 10/20/2018 11/1/2018 23 24 25 26 27 28 29
TX Renewal T542 10/11/2018 - Evening 10/17/2018 30,000 10/22/2018 11/1/2018 30
TX Renewal T542 10/11/2018 - Evening 10/18/2018 8,240 10/23/2018 11/1/2018
6,273 TX Renewal (Product Change) T821 10/11/2018 - Evening 10/18/2018 6,273 10/23/2018 11/1/2018 October 2018
4,048 MI Renewal T539 10/18/2018 - Evening 10/18/2018 4,048 10/22/2018 11/1/2018 Su M Tu W Th F Sa
3,371 MI Renewal (Plan Change) T816 10/18/2018 - Evening 10/18/2018 3,371 10/22/2018 11/1/2018 1 2 3 4 5 6
4,193 MI Renewal (Product Change) T819 10/18/2018 - Evening 10/18/2018 4,193 10/22/2018 11/1/2018 7 8 9 10 11 12 13
8,194
FL Renewal (Product Change) T818 10/17/2018 - Evening 10/18/2018 3,000 10/23/2018 11/1/2018 14 15 16 17 18 19 20
FL Renewal (Product Change) T818 10/17/2018 - Evening 10/19/2018 5,194 10/24/2018 11/1/2018 21 22 23 24 25 26 27
23,641 FL Renewal T537 10/17/2018 - Evening 10/19/2018 23,641 10/24/2018 11/1/2018 28 29 30 31
38,594 CA Renewal T175 10/18/2018 - Evening 10/22/2018 30,000 10/27/2018 11/1/2018
© 2018 Molina Healthcare, Inc.
New Member - Application Accuracy
Double check application and contact information from applicants for accuracy
Will help to avoid:
Incorrect premiums due to inaccurate DOB
APTC adjustments due to inaccurate income information
Undeliverable mail resulting in lapsed payments and termination for non-payment
Inability to contact the member concerning important medical or administrative issues
Molina cannot correct application inaccuracies. To correct inaccuracies in their application or *contact information, members must call the Exchange or access their online account with the Exchange.
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*Robocall and email outreach performed monthly for members with bad addresses instructing them to contact the Exchange to correct.
© 2018 Molina Healthcare, Inc.
New Member Application - Data Inconsistencies
Upon submitting an application, members must provide all documents required by the Exchange to support their application for coverage.
Types of documents the Exchange may request to prove identity, eligibility status, or income:
Citizenship
Immigration
Yearly Household Income
Self-Employment
Unearned Income
Veteran Status
Incarceration
American Indian / Alaska Native
Employer-Sponsored Coverage
No Minimal Essential Coverage
Residency
Social Security Number
Failure to submit documents within 90 days will ultimately result in either a loss of APTC and/or eligibility for coverage. Members will not be able to apply again until the following Open Enrollment period.
CMS and Covered CA send notices to members advising what information is needed and by when to avoid termination of eligibility or loss of APTC. As of July 2017, Molina no longer sends a subsequent notice for FFM members.
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© 2018 Molina Healthcare, Inc.
Communications Process for New Members
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Application
Payment PCP Selection
Start
Welcome letter Binder Invoice
ID Card andWelcome Kit
Members can register for Autopay during enrollment application
• Members who do not pay the full binder upon application will not have the ability to select a PCP.
• A PCP will be selected for them.
If payment made upon application, first invoice will show $0 balance
During OE, binder reminder robocall and email outreach is
performed
Correspondence triggered daily when 834 file transaction is received from the ExchangePCP is auto-assigned upon receipt of the
enrollment file from the Exchange
© 2018 Molina Healthcare, Inc. 62
Binder invoice mailed upon receipt of enrollment file
from the Exchange and monthly thereafter
(No paperless option at this time)
Binder Due Date
CA, FFM, WA Binder Due Date is 1st of coverage effective
month
Premium Due Date thereafter is:
25th of the month prior to the coverage effective month for FFM and WA
26th of the month prior for CA, or 4 business days prior to the beginning
of the coverage effective month, whichever is earlier
AutoPay
• Autopay withdraws on the 23rd of the month, or next business day
• December Autopay withdraw date will be pushed to 12/28/18 to
allow time for enrollments to process and the correct amount to be
withdrawn for January coverage
Payment Channels offered by Molina
(always include the Subscriber ID or Account Number with
payments to avoid processing delays)
1. AutoPay – for convenience and peace of mind.
Register at MyMolina.com
2. Online (Mobile Device or Desktop) - can use savings
or checking account, credit or debit card at
MolinaPayment.com. Or log in to MyMolina.com.
3. IVR – savings or checking account, Visa, MasterCard
or Discover card.
4. Mail – submit payments with coupon from invoice.
Allow 15 days for receipt and processing.
5. Cash – go to MoneyGram.com to find a location, or
call (800) 666-3947.
Member Services phone number and hours are located on the
invoice and welcome letter
Invoicing and Payment Options
© 2018 Molina Healthcare, Inc.
Welcome Letter
Sent upon receipt of enrollment transaction from the Exchange
Messaging:
Subscriber ID
My Molina registration
How to Make Premium Payments
PCP Selection Options / Auto-Assignment
Wellness Check Appointment Information
ID Card – process and timing to receive
Drug Formulary location
Member Services – contact information
Accessibility to information – language and disability options
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© 2018 Molina Healthcare, Inc.
Member ID Cards
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Important Information about ID Cards Mailed only once the full binder payment is received and posted In paper form (not laminated) Comes in a large envelope, appears first in the package, must be torn along the perforated line Includes one ID card per covered family member ID cards can be printed from MyMolina.com Available on mobile devices and can be printed or emailed Can be used by providers and facilities as a valid ID card where accepted ID card templates may vary slightly based on state regulations – sample below
Front Back
Timing• New Members - Sent once full binder payment is received and processed• Active Renewals – Sent as members actively renew during Open Enrollment• Passive Renewals – Sent in early January
© 2018 Molina Healthcare, Inc.
Welcome Kit and Renewal Kit Contents
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Contents ID Card for each covered member of the family Effective Date of Coverage Cover Letter including important information and tips – varies slightly by state
For Texas members who select the Consumer Choice or Options product, the kit includes a form that must be completed, signed and returned to Molina per Texas state law.
For CA members, the cover letter provides information on Timely Access to Care and how to file a grievance.
Privacy, Security, and HIPAA Information Financial Information Privacy Notice (except CA) 1557 Non-Discrimination Notice and Limited English / ADA statement plus taglines in
top 15 languages per state
Welcome Kit Contents Renewing Kit Contents
© 2018 Molina Healthcare, Inc.
My Molina – Self Service Member Tool
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MyMolina.com
View invoice and real-time balance Change PCP
Sign up for AutoPay, or make a payment
View Claim History
View Plan and Benefits Print ID Card
View/Print SBC or EOC Get Reminders for Health Services
View Drug Formulary …and much more!
© 2018 Molina Healthcare, Inc.
Other Notices - Premium Billing
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1. Notice of Enrollment Separation (Binder Cancellation Notice)
Cancellation occurs one month after the coverage effective date Notice is triggered once cancellation is processed
2. AutoPay Notices
AutoPay Confirmation – upon registration AutoPay Cancellation Letter
Upon member request to disable Autopay via MyMolina.com Can be disabled up until the morning of the 23rd of the month to be effective the next
coverage month Also triggered by Enrollment termination or upon notification by Chase that the member’s
bank account is no longer active AutoPay Non-Sufficient Funds – as result of Autopay run on the 23rd of the month AutoPay Disabled – triggered the day before the Autopay run (22nd of the month)
Initiated by Molina Notice sent when AutoPay has been disabled when there is complete loss of APTC and an
increase in the member responsibility amount of $100 or greater
3. Grace Period Notices Past Due – sent with the monthly invoice when the member has an outstanding balance Termination for Non-Payment
Sent after grace period has expired Three months grace period for APTC Members One month grace period for Non-APTC Members, except 10 days in Florida, Ohio and
Wisconsin, and 15 days in UT
4. Refund Notices (Full, Partial, Denied)
© 2018 Molina Healthcare, Inc.
Accessibility of Information
Translation, interpretation and accessibility
Molina automatically sends enrollment and billing materials to members in either English or Spanish.
Molina provides translation and interpretation services in at least 150 languages upon request at no additional charge as required by federal law.
Molina provides information in other formats such as Braille, audio, or large font for members with disabilities at no additional charge.
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Regulatory Update
Broker Fraud!
• All 200 policies written by one insurance agency under one NPN number.
• At least 5 addresses were used dozens of times which were found to be homeless shelters, mental health care centers, PO Boxes and the like…
• Dozens of members only phone number was the number of the insurance agency, or the homeless shelters
• Dozens of members had fake email addresses or emails of the insurance agency
• ALL 200 policies had $0 net premium owed by the member since someone who earned exactly $12,000 and chose a bronze plan in Florida received 100% APTC
• All 200 policies had no claims
• All 200 policies had no calls from members. Except one.
Regulatory Update
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Brokers: Do not list your email address on consumer
accounts
• Never enter your own agent or broker professional or company email or
mailing address on a consumer’s application.
• You also should not create or use dummy addresses in place of the
consumer’s email or mailing address.
• Consumer accounts should only have the consumer’s (or his or her
legally authorized representative’s) email and mailing addresses.
• Only consumer email and mailing addresses should be entered on
Marketplace applications.
Regulatory Update
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Prohibition on Creating ConsumerHealthCare.gov Accounts:
• Only a consumer or his or her legally authorized representative may
create a username and password for a HealthCare.gov account and should
not share this information with third parties, including agents and
brokers.
• You can assist the consumer in creating his or her account, but the
consumer or a legally authorized representative must enter his or her own
information into the application.
• You may not log in to HealthCare.gov on a consumer's behalf (i.e., using
the consumer's HealthCare.gov account).
Regulatory Update
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Homeless Shelters
• If a consumer is homeless or in transitional housing:
– They can submit a reference letter from a person in their state who can
confirm they live in the area permanently. This could be a friend, family
member, or caseworker. This person must also confirm their own residency
by providing proof of residency documents.
• A statement that the address is a homeless shelter or drop-in center is insufficient
for a rescission request to be approved because these are both allowable for
homeless people who enroll through the FFE.
– Document discussions you had with shelter staff if they said the enrollee is
unknown to them.
Regulatory Update
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Broker Specifics
Molina’s Guiding Principles for Broker
1. We provide quality services to our members throughout the processing of
their enrollment, billing, customer servicing, and claims-related transactions
2. We advocate for the brokers and take ownership for their entire Marketplace
experience
3. We provide an efficient and positive experience in all broker interactions,
including providing the knowledge and self-service tools necessary for
brokers to be effective
4. We pay competitive compensation and incentives accurately and in a timely
manner
5. We seek to contract with agencies / brokers who share Molina’s values and
operate in compliance with Molina policies and with all federal and state
regulations
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Broker
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Have you logged into your Broker Portal?
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Molina Broker Portal – VUE
Passwords reset every 365 days
Look at your Book of Business (BOB) for policy status and paid through date.
Enhancements and updates coming!
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Automated onboarding system enhancements: Termed agents may now re-onboard with us using the automated system.
No more manual process
Agents will pay a $60 non-refundable background fee
Within 30 days of a downline agent completing the onboarding process, MGA’S must review and provide their approval or downline agent will be denied
Courtesy Notifications for expiring E&O’s and Licenses will be sent at 60 and 30 days
No more suspensions – agent terminations will automatically be processed
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Book of Business enhancement:
Agents will now see what the member’s monthly premium is.
Passwords: Passwords will expire in a year
Commission Statements: Adjustments tab will show subscriber ID #
Renewal leads will be vetted by MP BSU and IT QA: CA renewal leads will be loaded into broker portal by Oct 1
FFM States and WA State renewal leads will be loaded into broker portal by Nov 1
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Enhanced Direct Enrollment (EDE):
Issuers have their Healthcare.gov – all consumer functionality available directly on HealthSherpa, with full API access to Federal Data
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Enhanced Direct Enrollment (EDE):
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Enhanced Direct Enrollment (EDE):
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Enhanced Direct Enrollment (EDE):
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Enhanced Direct Enrollment (EDE):
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MP Broker Communication And Resolution Experts Team! (MP BROKER CARE TEAM)
What type of escalated issues will the MP Broker CARE Team work to resolve?
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What types of escalated issues will team work to resolve?
Access to Care If your Molina client is seeking immediate medical services and/or medications, you may contact the
MP CARE Team. (Please note: Member should always reach out to Member Services)
Billing Issues Claims Enrollments Member Services Prior Authorization
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How do I contact the MP Broker Care Team?
Phone #855-885-3179 and choose OPTION 2Note: This line is for our Broker partners only! This number is not for members to call.
Email Must use Molina Client Escalated Issue Form.The more information you provide will helps us to provide resolution.
Send completed form to us at: [email protected]
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This template needs to be completed.
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BSU (Broker Support Unit) Ways we can help: Marketing Material Distribution Broker Communications, i.e., eBlasts Process your Molina appointment and contracting to sell our MP products CARE Team-Member Look Up/Issues/Resolution Commission Questions/Issues
Broker Support Unit Team:Jamie Neslen, DirectorRhonda Clark-Manager over CARE Team, Contracting & OnboardingSummer Brown- Manager over Commission & Recon, Broker Services
Contact Info: Molina Marketplace
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BSU (Broker Support Unit)
Phone #: 1.855.885.3179 Broker Services - # 1 [email protected]
Broker Care Team- # 2 [email protected]
Commission Team- # 3 [email protected]
Contracting Inquiries - # 4 [email protected]
Monday through Friday – 8:00 AM to 5:00 PM (CST)
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Northern & Central Florida:BCM: Jocelyn CastilloEmail: [email protected]: (813) 453-7525
Ohio and Michigan:BCM: Kahassai TafeseEmail: [email protected]: (614) 623-8267
Broker Channel Manager: Contact InformationWashington:BCM: James (Jim) MaguireEmail: [email protected]: (253) 441-9182
California:BCM: Amy DeMarcoEmail: [email protected]: (916) 761-8766
Utah, New Mexico & Texas:BCM: Adam GrimaldoEmail: [email protected]: (818) 428-9205
Hours of Operation
Non-Open Enrollment Period Open Enrollment Period
December 16 thru Oct 31
Monday thru Friday
7:00am to 6:00pm MST
Nov 1 to December 15
Monday thru Friday
6:00am to 7:00pm MST
Saturdays
7:00am to 4:00 pm MST
Questions