2017 wisconsin product launch & agent...
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Awards-Top Marketplace Agentsand Agencies for 2016
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1. Transition Health Benefits-Kevin Truebenbach &Todd Catlin
2. Jack Schroeder & Assoc- Brian Schroeder
3. CLIFF Consulting-Jack Kellner
4. Agent Pipeline-Ryan Kimble
5. FHK, Inc- Bill Kravit
2016 Top 5 Wisconsin Agencies
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6. Health Markets
7. JMS Brokerage
8. The Insurance Center (T.I.C)
9. Ideal Concepts (American Insurance Organization)
10. Ulness Health Insurance
2016 Top Wisconsin Agencies-Honorable Mentions-
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2016 Top 15 Wisconsin Agents1. Dalton Mullens-Agent Pipeline2. Kevin Truebenbach-Transition Health Benefits3. Michelle Rice- Agent Pipeline4. Brian Marmes-CLIFF Consulting5. Peter Wegmann-JSA6. Dustin Schlesner-JSA7. Paulette Raminski-Transition Health Benefits8. Thomas Griesman-Transition Health Benefits9. Brian Leonhardt-JSA10. Ken O’Dierno-Ulness Health Group11. Dan Monahan-Transition Health Benefits12. Huseyin Macar-Transition Health Benefits13. Nicole Vorel-FHK, Inc14. Christian Laur-FHK, Inc15. Dean Rhodes-T.I.C. Inc
Overview
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The Molina Mission / Molina today and in the future
Regulation Update
Provider Network
Broker Support
Molina Marketplace 2017
Questions
Pharmacy Education
The Molina Story
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What We Do
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2016 Broker Performance
Marketplace Effectuated Membership as of Apr 25, 2016
• Source Data: QNXT, ASPE
Total Membersas of: May 30th 2014(End of 2014 Open
Enrollment)
260,870Total Renewed and
Effectuated MembersAs Of 3/11/15
Nearly 85% binder/initial payment rate for MP2016!
23,219
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148% Growth from 2015
650KMembers25,383
77,618
56,771
18,719
142,765
66,026 3,722
11,580
247,079
Source Data: 2016 Disenrollment Report
Molina’s Guiding Principles for Broker
1. We provide quality services to our members throughout the processing oftheir enrollment, billing, customer servicing, and claims-related transactions
2. We advocate for the brokers and take ownership for their entire Marketplaceexperience
3. We provide an efficient and positive experience in all broker interactions,including providing the knowledge and self-service tools necessary forbrokers to be effective
4. We pay competitive compensation and incentives accurately and in a timelymanner
5. We seek to contract with agencies / brokers who share Molina’s values andoperate in compliance with Molina policies and with all federal and stateregulations
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Broker
Actual vs Potential
Source Data: 2016 Disenrollment Report.Enrollment is prior to binder cancellations.
Total Jan - MarEnrollment
579,134
Jan - MarBinders Paid
496,829
Jan - MarEffectuation Rate:
86%
39,3
5689
%
116,
965
87%
1,64
067
%
1,27
770
%
6,93
358
%
3,42
974
%
2,41
596
%
12,8
6676
%
151,
989
82%
Key Point:Every 1% increase in binder payment rate equates to $16.2M annualized revenue
Key Point:Every 1% increase in binder payment rate equates to $16.2M annualized revenue
State Jan - Mar Enroll Paid Binder EffCA 72,135 62,431 87%FL 181,870 159,686 88%MI 4,210 3,441 81%NM 19,015 16,451 87%OH 11,651 9,537 82%TX 159,157 129,027 81%UT 56,261 50,397 90%WA 25,028 21,234 85%WI 49,807 44,655 90%
Total 579,134 496,829 86%
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VarianceCA 20% TX 31%FL -3% UT 35%MI 4% WA 11%NM 9% WI 21%OH 23%
29%
88%
16% 19% 19%14% 17% 19%
26%
49%
85%
20%28%
42% 45%52%
30%
47%
0%
20%
40%
60%
80%
100%
CA FL MI NM OH TX UT WA WI
Broker Enrollment to Total EnrollmentJan – Apr, 2015 vs. Jan – Mar, 2016
2015 2016
Source Data: Lakshmi’s Broker Report.Enrollment is after binder cancellations.
Agency Benchmarks by State
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State High Low AverageFL 80,421 1 2,356CA 6,132 1 146TX 6,011 1 408WI 5,960 1 364UT 3,695 1 333NM 1,819 1 70WA 1,656 1 67OH 580 1 62MI 223 1 20
TotalAverage 572High 80,421Low 0
Top 50 NationalAverage 6,726High 80,421Low 1,135
Top 10 AgenciesAverage 23,959High 80,421Low 6,990
Agency BenchmarksNationally
2017 Regulation Update
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Licensure and Product Presentation Must have valid license to sell
insurance with State of Wisconsin
Disclose:– Licensed agent in Wisconsin– Companies you represent– That you will receive a
commission
Clearly Represent the Product:Covered Services– Co-pays– Drugs (formulary / tier / PA
requirements)– Network
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All agents and brokers must also complete the followingactions to sell on the Marketplace in 2017: Complete an agent/broker profile on the new Marketplace Learning
Management System (MLMS) Enroll in the desired Marketplace training (i.e. Individual and/or SHOP) on the
MLMS or through a CMS-approved vendor via the CMS Enterprise Portal Complete assigned training courses and pass exams through the MLMS or
through a CMS-approved vendor via the CMS Enterprise Portal Read and accept the applicable Marketplace Agreement(s) on the MLMS
The new MLMS will replace the previously-used MLN and can be accessed via the AgentBroker Registration Status page on the CMS Enterprise Portal.
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2017 Open Enrollment and Re-determinations
November 1, 2016: Open Enrollment starts — first day you can enroll in a2016 Marketplace plan
January 1, 2017: First date 2017 coverage can start
January 31, 2017: 2017 Open Enrollment ends If you don’t enroll in a 2017 plan by January 31, 2017, you can’t enroll
in a health insurance plan for 2017 unless you qualify for a SpecialEnrollment Period.
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2017 Existing Member Notifications
Between Oct. 1- Nov. 15, formal renewal letters will be sent advisingexisting enrollees of premium and plan changes existing. All enrollees who need to update their eligibility information for 2015 will do so
through the Healthcare.gov application (similar to reporting a life change). During the open enrollment period, existing enrollees will be able to change plans.
Molina to send out initial notification mid September and formalnotification in October
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2017 Re-determinations The majority of enrollees who do not proactively take action by
December 15 will be automatically renewed. Enrollees stay with same plan and product (if available) The majority of enrollees who authorized the FFM to obtain
updated income data will have 2017 eligibility established identicalto the most recent 2016 determination, including APTC and CSR. Note: If based on new income data, the enrollee has a large income changes, such
as above 500% FPL or more than a 50% change, the enrollee will be continued inthe same plan for 2016, but APTC and CSR will end 12/31/15.
Enrollees who didn’t authorize the FFM to obtain updated incomedata will be renewed in the same plan for 2017, but APTC and CSRwill end on 12/31/16.
Update information in the Marketplace via Healthcare.gov =a new determination for 2017.
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2017 Effective Dates New applications and enrollee plan changes may be submitted
11/1/16 through 1/31/17
Changes will be consistent with regular effective dates: Change by the 15th, effective first of following month. Changes after the 15th will be effective first of the second following month
(individual will retain prior plan for the next month for selections after the 15th).
Date Plan Changed Effective Date of NewPlan
11/1/16 - 12/15/16 1/1/201712/16/16 - 1/15/17 2/1/20171/16/17 - 1/31/17 3/1/2017
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Special Enrollment PeriodsRegardless of whether you purchase insurance through the exchange or off-exchange,the annual open enrollment window applies. Outside of Nevada, you cannot enrolloutside of open enrollment unless you have a qualifying event, such as: Marriage / Divorce Becoming a U.S. citizen, Birth or adoption, Involuntary loss of other health coverage (this includes loss of coverage when
health plans exit the market, as was the case with 12 CO-OPs in 2015) Permanent move to an area where new health plans are available (as of July
11, 2016, this will only apply in most cases if you already had coverage prior toyour move).
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4 Additional Special Open Enrollment Triggers Individual plan renewing outside of the
regular open enrollment. HHS issued aregulation in late May 2014 thatincluded a provision to allow a specialopen enrollment for people whosehealth plan is renewing – but notterminating – outside of regular openenrollment.
Becoming a United States citizen (thisqualifying event only applies within theexchanges – carriers selling coverageoff-exchange are not required to offer aspecial enrollment period for peoplewho gain citizenship or lawful presencein the US).
An error or problem with enrollment (ornon-enrollment) that was the fault of theexchange, HHS, or an enrollment assister.
Employer-sponsored coverage reducingbenefits such that it no longer providesminimum value, or becomes unaffordable(defined as requiring the employee to paymore than 9.66 percent of income for justthe employee’s portion of the coverage in2016).
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SEP and Proof of Eligibility Starting in 2016, Healthcare.gov will be requiring proof of eligibility for the most
common qualifying events.
Some state-based exchanges were already requiring proof, and health insurancecarriers also generally require proof of eligibility when people enroll off-exchangeduring a special enrollment period.
If you experience a qualifying event and wish to enroll in a plan during your specialenrollment period, be prepared to provide documentation of the qualifying event.
Molina Healthcare of WisconsinNetwork Operations
WFPN (Wheaton Franciscan Provider Network) Network of providers able to see
members at any of our in-networkfacilities, including Wheaton,Columbia St. Mary's and Aurora
400+ providers in network
New providers are being addedmonthly
Including but not limited to the followingproviders: Great Lakes Anesthesia and Pain Specialists Milwaukee Radiology Newborn Care Physicians Racine Anesthesia Services Advanced ENT Specialists Advanced Foot & Ankle of WI Children's Eye Center of Wisconsin Dermatology Surgery Associates Greater Milwaukee Plastic Surgeons Great Lakes Neurosurgical Associates Infectious Disease Specialists of SE WI Integrated Spine Care Milwaukee Hand Specialists Ophthalmology Associates Pulmonary & Critical Care Associates Wisconsin Bone & Joint
Marketplace Network Addition
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Marketplace Provider Network Wheaton Franciscan Services
Hospital services, primary and specialty clinics, behavioral health, ancillary services. Serving Milwaukee, Waukesha and Racine
United Hospital System Hospital services, primary and specialty clinics, behavioral health, ancillary services. Serving Racine and Kenosha
Ministry and Affinity Health Care Hospital services, primary and specialty clinics, behavioral health, ancillary services. Serving Fox Valley and Northeastern Wisconsin - Lincoln, Oneida, Vilas and Door
Columbia St. Mary’s Hospital services, primary and specialty clinics, behavioral health, ancillary services. Serving Milwaukee and Ozaukee
Aurora Health Care Hospital services, primary and specialty clinics, behavioral health, ancillary services. Serving Milwaukee, Southeastern Wisconsin, Fox Valley and north to Marinette
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Dickinson County Health System Located in Michigan offer access for Florence County and Marinette County members Hospital Services Primary and Specialty Services
Menominee Tribal Clinic Gerald L. Ignace Indian Health Center Other Essential Community Providers
Other Marketplace Providers
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Federally Qualified Health Centers(FQHC’s)Locations in Milwaukee, Waukesha and Kenosha Sixteenth Street Clinic Milwaukee Health Services Outreach Community Health Center Progressive Community Health Centers Kenosha Community Health Center
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All Marketplace Products:Out of Network / Balance Billing The use of non-participating providers including ER and Ambulance may
create a situation where members will be balanced billed.
Members that have been in the State Medicaid program will not beused to this nuance of being a Marketplace member.
We are currently looking at ancillary providers that may be used byparticipating providers that are non-participating themselves.
The member should make reasonable attempts to utilize participatingproviders.
2017 Pharmacy Update andPrior Authorizations
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Pharmacy Highlights1. Mail Order Benefit
Improves affordability and access Applies to Tiers 1,2,3, and 5 (Specialty Drugs
excluded) Easy On-line Ordering
2. Low Copay for Generics Removes financial barriers to care
3. Rx tier for Preventive Drugs available at $0copay Helps members know which prescriptions
are No Charge4. Expedited Review for Non-Formulary Drugs
Decision must be provided within 24 hours forstandard requests and within 72 hours for urgentrequests
Improves member access to non-formulary drugs
“Ask your doctorif Molina is
right for you”
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Pharmacy: Prior Authorizations Drugs requiring PA will be
notated “PA” in the formularylisting.
– Any drug not listed on the formularywould require a PA.
Physician must submit a PA formto Molina
– The inability of the prescriber toprovide the required information is thebiggest cause for delay in receivingapproval on a PA request, and mayactually lead to a denial.
It takes ONE (1) day onaverage for Molina torespond with Approval orDenial.
– Federal law requires a decisionwithin 72 hours for a standardrequest and within 24 hours foran expedited request
– Molina Marketplace does notprovide partial supplies ofdrugs. In urgent situations(defined by the nature of themember’s medical condition),the PA requests are reviewed ina more expedited manner.
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Pharmacy: Non-Formulary Drugs If a member’s drug is not on the formulary? Should the member ask the doctor for a
different prescription? Before speaking to a physician, please confer with the Molina pharmacy team and
ask them to identify what the formulary alternatives are for a medication, what thePA requirements may be, etc.
Can the agent find potential “Like” drugs? For example, Molina may cover a differentbrand or generic, but how does the agent/member know which alternative drugs arecovered? Please confer with the pharmacy team. See preceding question. Otherwise, agent
may give incorrect information. If an existing member’s drug(s) are not on the formulary, what alternatives do they
have? (1) Ask prescriber to submit a PA request, and hopefully the medication will qualify
for approval; (2) Ask physician to prescribe formulary alternatives).
Wisconsin Health InsuranceMarketplace
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11421
16944
12553
6601
12708
1952
2290
4000
8000
12000
16000
20000
Bron
ze
Silv
er 1
00
Silv
er 1
50
Silv
er 2
00
Silv
er 2
50
Gold
Trib
al
Enrollment by Plan
62,408 WI members as of July 11, 2016,more than double the 2015 membership.
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2016 Marketplace CMS National Membership Data
Household Income
38states* WI
<100% of FPL 3% 1%
100% to 150% of FPL 38% 29%
150% to 200% of FPL 25% 25%
200% to 250% of FPL 15% 16%
250% to 300% of FPL 9% 11%
300% to 400% of FPL 8% 14%> 400% of FPL 2% 3%
Electionby Metal
38states* WI Molina
WI
Catastrophic 1% 1% n/a
Bronze 21% 23% 18%
Silver 71% 70% 79%
Gold 6% 5% 3%
Platinum 1% 1% n/a
WI members are higher income, older, and more rural than the average for the 38 states on healthcare.gov.
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2016 Marketplace CMS National MembershipData38 States* WI Subscriber Data
9,625,982 239,034 total subscribers42% 38% were new enrollees58% 62% were re-enrollees61% 57% of active re-enrollees who switched plans$396 $455 average monthly premium before APTC$290 $330 average monthly APTC$106 $125 average monthly premium after APTC73% 73% average percent reduction in premium after APTC85% 84% had APTC59% 54% had Cost Share Reduction18% 37% in rural ZIP code
Persons inHousehold
Poverty Level(FPL)
1 $11,8802 $16,0203 $20,1604 $24,3005 $28,4406 $32,5807 $36,7308 $40,890
*Data set: 9.63 million members in the 38 states that use healthcare.gov during 2016 Open Enrollment (11/1/15 to 2/1/16).Data source: hhs.gov (ASPE issue briefs 3/11/16)Molina membership data as of 7/11/16
Molina Healthcare of Wisconsin
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2017 Molina Product Strategy - Key TakeawaysOur Mission Remains -
To provide quality healthcare services to people receiving government assistance
2017 Product Priorities –1. Retain and Grow our Membership through strong broker relationships
2. Renew our successful product portfolio with minimal cost share changes tosupport retention
3. Expanded Product Offering – Introducing “Molina Options” CMS StandardProduct Offering
4. Where possible, address financial barriers to obtaining healthcare
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Molina Marketplace – 2017 Renewal Plan HighlightsOverall –
We continue to be very excited about our renewal portfolio
a. With minimal changes to current plan cost shares, to promote retention and minimizeimpact on pricing position
Tweaks only to OOPM, Deductible, Emergency Room or Rx to maintain required ActuarialValue.
b. Bronze Plan Deductible Positioning will support better access to care
This high Deductible plan, now waives the Deductible for all Primary Careoffice visits, Other Practitioner office visits, Mental Health office visits, andSubstance Abuse office visits. This improves member access to the mostfrequently used services.
c. Silver 250 Plan – No more Pharmacy Deductible.
d. Emergency transportation benefit - Changing from Copay to Coinsurance.
e. Pharmacy benefits
Non-Preferred Brand Drugs and Specialty Drugs coinsurance increased for all plans
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Key Renewal Plan Design Features
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2017 Molina Renewal Plan Design Changes
▲= Deductible AppliesOther Practitioner =Certain specialties suchas Midwife, PhysicianAssistant, NursePractitioner
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2017 Molina Renewal Plan Design Changes
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2017 Molina Renewal Plan Design Changes
▲= Deductible Applies
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Molina 2017 Benefits At-A-Glance: RENEWAL PLANS
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Molina 2017 Benefits At-A-Glance: RENEWAL PLANS
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New 2017 Portfolio – “Molina Options”Overall – We are excited to introduce “Molina Options”, which are 2017 “CMS
Standard Plan Designs” Molina Options:
Supports our strategy to work closely with CMS on choice and comparability Allows Molina to introduce CMS national standard Silver and Bronze plans in
WI Expands choices to your clients to an additional six metal plans Will be highlighted on Healthcare.gov Provides choice in Plan Designs
Molina options Bronze – Deductible is waived for the First Three Primary Care Visits, and
for all Outpatient MH/SA Services, Preventive Services, PreventiveDrugs, Pediatric Vision, Generic Drugs
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New 2017 Portfolio – “Molina Options” CMS Standard Silver Plans – Benefit Design Variance
Silver Plan Benefit DriverMolina Options SilverPlans
Molina RenewalSilver Plans
Silver 250% FPL Deductible Higher LowerOOP Max Higher LowerPCP Higher LowerSPEC Higher LowerCoinsurance Lower HigherGeneric Rx Even Even
Silver 200% FPL CSR Deductible Higher LowerOOP Max Even EvenPCP Higher LowerSPEC Higher LowerCoinsurance Lower HigherGeneric Rx Even Even
Silver 150% FPL CSR Deductible Higher LowerOOP Max Lower HigerPCP Even EvenSPEC Lower HigherCoinsurance Even Even
Silver 100% FPL CSR Deductible Higher NoneOOP Max Even EvenPCP Higher LowerSPEC Higher LowerCoinsurance Lower HigherGeneric Rx Higher Lower
Comparing Silver Plans:Molina Options plans have: Higher Deductibles, PCP and
Specialty Copays, than ourRenewal Portfolio
But allow for plan choice,determined on Individual need
Allow you more flexibilityoptions for new business
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Molina 2017 Benefits At-A-Glance: NEW “MOLINA OPTIONS” PLANS
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Molina 2017 Benefits At-A-Glance: NEW “MOLINA OPTIONS” PLANS
My Molina
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24 hours once application is submitted successfully, Molina will beable to view in our internal member database.
Member will be able to create an account on Mymolina.com ormimolina.com
Once they create an account, member will be able to choose a PCP,make initial binder payment, and print ID cards
Note: Please make sure that you enter your NPN# when enrolling ontothe Molina Direct or Healthcare.gov site to attach your information tothe application.
My Molina Site
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Reminder:Cannot print
ID tilleffective
date.
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Broker Specifics
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Have you logged into your Broker Portal?
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Molina Broker Portal – VUE
Passwords reset every 60 days Look at your Book of Business (BOB) for policy status
and paid through date. Enhancements and updates coming!
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Broker InformationWelcome to MolinaMarketplace.com –
• Easy Access to Broker Support Tools
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Marketing Materials
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Marketing Materials
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NEW! MP Broker Communication AndResolution Experts Team!(MP BROKER CARE TEAM)
What type of escalated issues will the MPBroker CARE Team work to resolve?
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What types of escalated issues will team work toresolve?Access to Care
If your Molina client is seeking immediate medical services and/or medications, you, the agent may contact the MP CARETeam. (Please note: The CARE Team doe not take member calls. Member should always reach out to Member Services)
Billing Issue:Invoice RegenerationNon-Applied PaymentRefundUpdate Accounts/Receivable (A/R)Update Payment ApplicationBinder Payment & Pending Termination Restriction Removal
Enrollments:APTC AdjustmentEligibilityMissing DependentNo Member profileRestriction RemovalVoluntary Cancellation
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How do I contact the MP Broker Care Team? Phone #855-885-3179 and choose OPTION 2
Note: This line is for our Broker partners only! This number is not formembers 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 tobe 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-ManagerTom Grady, Supervisor Broker ServicesIlse Galaz, Supervisor Contracting & OnboardingSummer Brown, Supervisor Commission Recon
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BSU (Broker Support Unit)
Phone #: 1.855.885.3179
Broker Services - # 1 [email protected] Care Team- # 2 [email protected] Team- # 3 [email protected] Inquiries - # 4 [email protected]
Monday through Friday – 8:00 AM to 5:00 PM (CST)Extended Hours (OEP)-Nov 1 to Jan 31
Monday thru Friday 7:00am to 8:00pm CSTSaturdays 8:00am to 5:00 pm CST
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Why Sell Molina? Deductible applies to OP Facility Services and IP Services only.(Silver &
Gold Plans) Bronze Plan Deductible Positioning will support better access to care New Options plans=larger portfolio Molina does not rate up for smokers HMO but no referral needed for specialist Reoccurring payment and PCP at time of enrollment Network of hospitals and providers Broker CARE team; Exceptional Broker Support Unit
Questions