New York Health Benefit Exchange

Danielle HolahanDeputy Director

IPROJune 4, 2013

Topics for Today

• What is the Exchange?• Who will Enroll through the Exchange?• Accomplishments to Date• Qualified Health Plan Certification Process• Health Plan Quality and Enrollee Satisfaction

Requirements• Going Forward to October 1, 2013

• Organized marketplace – Easily compare health plan options – Makes available tax credits and cost-sharing subsidies– Easily enroll in qualified health plans

• Two programs – Individual Exchange– Employer Exchange, which is called the Small Business

Health Options Program, or “SHOP”

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What is an Exchange?

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

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Functions of the Exchange

• One million people will gain insurance

• Exchange enrollment is estimated to be 1.1 million people:

Individual Exchange (58%)

SHOP Exchange (42%)

450,000 615,000

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Full Implementation Impact of Exchange and Reforms in New York

SHOP Exchange

44%

Individual Exchange – with

Subsidy43%

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Full Implementation Impact of Exchange and Reforms in New York

Individual Exchange –

without Subsidy15%

Exchange Enrollment

13%

12%

23%

13%

40%

SHOP Exchange

Under 138% FPL

138-200% FPL

200-300% FPL

300-400% FPL

Above 400% FPL

4%

43%

25%

14%

14%

Individual Exchange

Source: Urban Institute, Characteristics of Nonelderly New Yorkers Likely to Enroll in the Health Insurance Exchanges Under the Affordable Care Act, February 2013.

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Enrollee Characteristics, by Income

64%

36%

Individual Exchange

63%

37%

SHOP Exchange

EnglishOther

Note: Includes enrollees over 5 years of age.Source: Urban Institute, Characteristics of Nonelderly New Yorkers Likely to Enroll in the Health Insurance Exchanges Under the Affordable Care Act, February 2013.

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Enrollee Characteristics, by Language

64%

18%

3%2%

1%2%

1%

9%

Individual ExchangeEnglish

Spanish

Chinese

Hindi and related

French

Korean

Russian

Other

Note: Includes enrollees over 5 years of age.Source: Urban Institute, Characteristics of Nonelderly New Yorkers Likely to Enroll in the Health Insurance Exchanges Under the Affordable Care Act, February 2013.

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Enrollee Characteristics, by Language

Premiums decline in small group and individual market in all scenarios modeled

$2.6 billion in federal tax credits per year for individuals and small businesses further reduce the cost of coverage

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Impact of Exchange and Health Reform in New York

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Choice• Employers and Employees regard expanded choice as a key advantage to using

the exchange.

Administrative Simplicity• The exchange provides monthly billing to employers among other

administrative simplifications.

Tax Credits• The exchange will be the exclusive place to access small business tax credits in

2014.

Defined Contribution• 76% of respondents believe this feature helps predict costs.

SHOP – the Value Propositions

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 services organization

Invited Health Plans to Participate in the Exchange

Invited organizations to apply to be In-Person Assistors/Navigators

Received conditional certification from HHS in December 2012

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Key Accomplishments to Date

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, 2013

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IPA/Navigator RFA Released February 13, 2013

Goals:

• Build public awareness of the Exchange

• Build support, educate and earn by-in from organizations who work with targeted populations

• Educate individuals and small businesses about health insurance and the benefits of enrolling in the Exchange

• Actively focus outreach efforts on the most vulnerable and difficult to reach populations and address their needs and concerns

• Drive potential enrollees to an enrollment mechanism including online, by phone, in-person and by mail

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Grassroots Outreach

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

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Health Plan Invitation Released January 31, 2013

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Insurer Requirements

• 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

• Insurer must agree to participate in its entire approved Service Area, unless granted an exception by the Exchange

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QHP Standard Products

Insurers Must Offer: • 1 standard product, at every metal level, in every

county of their service area that includes the Essential Health Benefits

• A standard Child only product, at every metal level• A standard Catastrophic product

— If there is more than one catastrophic product offered in a county, the Exchange may allow QHPs the option of not offering this product

• Pediatric dental benefits, as a separately priced benefit for each standard and non-standard product proposed— If sufficient Stand-alone Dental products are available,

QHPs may elect not to offer pediatric dental

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QHP Non-Standard Products

Insurers May Elect to Offer:

• Up to 3 non-standard plans, per metal level

• Non-standard product means:• Additional benefits not included in the Essential Health Benefits

• Insurers may substitute benefits in the following EHB categories:— Preventive/Wellness/Chronic Disease Management — Rehabilitation/habilitation

• Standard product with a different provider network

• Variations on standard cost sharing

• Issuers may elect to offer non-standard products in a portion of their Service Area

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Out-of-Network (OON) Benefits

• OON benefit will be required to ensure that consumers have the same choices in the Exchange as in the outside market – If an Insurer offers an OON product outside the

Exchange in a county, Insurer is required to offer an OON product inside the Exchange in the same county

– Must be offered at the Silver and Platinum levels

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Network Adequacy

• All QHP and Stand-Alone Dental Products will be subject to network adequacy test

• Requirements will initially mirror those used by DOH for HMO products

• QHPs will be required to use “best efforts” to contract with Essential Community Providers and, at a minimum, must include one FQHC and one tribal operated health clinic in each county to the extent one is available

• All plans must submit provider networks on a quarterly basis; over time, will be required on a monthly basis

• Network information will be available to consumers during the plan selection process

www.HealthBenefitExchange.ny.gov

Quality and Enrollee Satisfaction

All QHPs must adhere to the following five criteria in order to demonstrate quality of care and enrollee satisfaction:

1) Develop and maintain a quality strategy that is updated annually with progress reported to DOH

2) Participate in DOH Quality Assurance Rating Requirements (QARR)• Quality indicators in QARR are primarily adopted from the National

Committee for Quality Assurance (NCQA ) Health Care Effectiveness Data and Information Set (HEDIS), with NYS specific measures included

• QARR submissions with respect to Exchange enrollment is anticipated to begin on or around June 2015 for calendar year 2014

• All QHPs must have:― HEDIS Volume 2, programming for all required measures (either in-

house capability of through a vendor), ― An NCQA audit conducted by a licensed audit organization of their

QARR data prior to submission to the DOH, and ― A certified CAHPS vendor to administer CAHPS

www.HealthBenefitExchange.ny.gov

Quality and Enrollee Satisfaction (continued)

3) Conduct an annual survey of eligible members using the standardized Consumer Assessment of Health Care Providers (CAHPS) tool

• Initial CAHPS survey anticipated to be scheduled on or around fall of 2014

4) Develop an infrastructure that allows for the implementation of quality initiatives

• Includes administration of member services, offering member outreach/education or incentive programs, offering physician training and/or incentive programs, supporting systematic changes at the practice level, etc

5) Meet Accreditation requirements when required by the Exchange

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QHP Certification Process and Timeline

• 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 are due May 15th

• Anticipated notification of Certification is July 15, 2013

1) New affordable and comprehensive health insurance options will be available for New Yorkers

2) Open enrollment begins October 1, 2013 for coverage that begins January 1, 2014

3) If you earn less than $45,960 as an individual or $94,200 for a family of 4, you may be eligible for financial assistance that will make coverage more affordable

4) You will not be denied health insurance on the basis of a pre-existing condition

(continued…)

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7 Things You Need to Know:

5) All health insurance options will offer a comprehensive array of services

― Preventive services will be offered at no cost to you

6) You can get help enrolling in coverage:— Call center— In-person assistor (Navigator or broker)— On-line via web chat

7) You pick the plan that is best for you:— Compare your plan choices based on price, provider

network, or quality score

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7 Things You Need to Know (continued):

Executive Order Issued - April 2012

NY completes HHS Design Review - October 2012

NY submits Blueprint to HHS – November 2012

NY receives conditional certification from HHS to operate a state-based Exchange - December 2012

Grassroots Outreach activities begin - April 2013

• Health Plans Selected for participation in 2014 - July 2013

• In-Person Assistor/Navigator Program begins – September 2013

• Customer Service opens for business – September 2013

• Advertising Campaign launched – September 2013

• Applications accepted – October 2013

• Coverage starts – January 2014

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Exchange Timeline

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www.HealthBenefitExchange.ny.gov