Delaware Health Benefit Exchange (HBE) Project Update

Delaware Health Care Commission Meeting: November 1, 2012

Topics • Updates on key milestones, progress to-date and upcoming

activities

• Review of analysis of pediatric dental plan options to supplement for EHB benchmark• FEDVIP vs. Medicaid/DHCP

• HCC vote for selection

• Delaware Standards for certifying Qualified Health Plans on the Exchange• Summary of stakeholder input

• Recommended modifications to initial draft standards

• HCC vote for approval

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Delaware Exchange Project

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Key Accomplishments To-Date Delaware chooses to implement a State Partnership Exchange

• State retains critical Plan Management and Consumer Assistance functions in-state, and deferring much of the large-scale technical infrastructure to the federal government

• State will perform all final eligibility determinations for Medicaid/CHIP, but will defer administration of the Reinsurance program for the Exchange to the feds

Essential Health Benefits benchmark selected the Blue Cross/Blue Shield Small Group EPO plan

• supplemental pediatric dental to be selected at today’s meeting

Recommendations for state QHP Certification Standards developed and reviewed by stakeholders

Initial Plan Management Processes and organizational structure designed Plan Management support systems identified and key interfaces for Issuer data

submission/certification defined Marketplace Assister selection criteria, roles/responsibilities and conflict of

interest standards developed

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Update: Exchange Timeline

September 2012: • Final recommendation on Essential Health Benefits benchmark submitted to

HHS• Final recommendation on Qualified Health Plan (QHP) selection process

October 2012:• Continue activities to engage Consumer Assistance and Outreach partners in

planning process

November 2012:• Final recommendations on all QHP policies, including certification criteria and

other standards related to plan management functionality• Finalize draft QHP process, rating criteria, and certification application• Final recommendations for Navigator and In-Person Consumer Assisters

certification criteria and phased approach to Outreach and Education• Finalize readiness checklists and training materials for Navigators and In-Person

Assisters• Submit Declaration Letter confirming Exchange model to HHS

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Update: Exchange Timeline

December 2012• Exchange readiness review conducted by Federal government

January 2013 – March 2013• State moves forward with operational implementation of plan management and

consumer assistance functionality• Begin accepting QHP applications

April 2013 – October 2013• Launch full outreach and education campaign in preparation for open enrollment

August 2013 • Exchange readiness complete

October 2013• Open enrollment begins for QHP plans through the Exchange

January 2014• Plan coverage year commences

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Upcoming Project Activities

Policies

Approve Delaware QHP Certification Standards (HCC 11/1/12) Select and approve Pediatric Dental Plan to supplement EHB Benchmark (HCC

11/1/12)

Agreements

Finalize Federal-to-State MOUs and Data Sharing Agreements Develop Inter-agency MOUs and Data Sharing Agreements

Operations Finalize QHP application Finalize In-Person Consumer Assistance Program Plan Finalize Delaware Exchange Organizational and Operational Framework Finalize Exchange integration protocols and interface design based on future

federal guidance

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Additional areas of focus

Delaware is looking for additional guidance from the federal government on a number of items so that it can complete design activities•Funding model for Partnership states—when will guidance be provided and what will it cover?

•FFE/State Agreements—what is the federal government’s timeline for finalizing agreements with Partnership states?

• MOU• Data Sharing Agreements

•Plan Management• How will the Call Center and federal Account Manager work with the state?• What complaint data will need to be captured and transferred between the state

and the FFE?

•Consumer Assistance• Navigator and Outreach (tools, process, materials, timelines)

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Essential Health Benefits• The Affordable Care Act requires that any health insurance plan offered to

an individual or small business must meet certain standards.

• These standards, known as essential health benefits, must cover the ten broad categories of services listed below.

• This list applies to health insurance plans offered inside and outside of the Exchange and represents the minimum services that must be covered. Health insurance plans may cover additional services at their own discretion.

• Essential Health Benefit (EHB) Service Categories1. Ambulatory patient services

2. Emergency services

3. Hospitalization

4. Maternity and newborn care

5. Mental health and substance use disorder services, including behavioral health treatment

6. Prescription drugs

7. Rehabilitative and habilitative services and devices

8. Laboratory services

9. Preventive and wellness services and chronic disease management

10. Pediatric services, including oral and vision care

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EHB Supplemental Pediatric Dental

FEDVIP Dental Plan vs. Medicaid/CHIP Dental Plan1. Federal Plan is more robust, especially with regard to the following dental

services:• major restorative• oral surgery• prosthodontics• orthodontics

2. Guidelines applied under CHIP would translate to hard limits in commercial plans

3. Continuity of Care consideration:• CHIP Plan will more readily address the continuity of care for children who

'churn' back and forth between QHP plans and Medicaid coverage.• CHIP plan may be easier for dental providers to understand since they are

familiar with what is already covered under Medicaid and CHIP

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FEDVIP vs. CHIP Dental Plan

• Review Dental plan comparison sheet handout

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Delaware QHPs defined

An Exchange-certified qualified health plan (QHP) is a health insurance plan offered inside the Delaware Exchange that:

• Meets the federal criteria for certification described in section 1311(c) [42 USCS § 18031(c)];

• Meets additional, state-defined standards;

• Provides the Essential Health Benefits package approved and recognized by the state;

• Is offered by a health insurance issuer that is licensed and in good standing to offer health insurance coverage in Delaware, and agrees to offer at least one qualified health plan in the bronze, silver and gold level in the Delaware Exchange.

Essential Health Benefits (EHBs) represents the minimum services that must be covered by plans offered both inside and outside the Exchange. Health insurance plans may cover additional services at their own discretion.

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State Standards for Qualified Health Plans (QHPs)

• The Health Care Reform (HCR) workgroup and the Department of Insurance (DOI) have developed recommendations for state-specific QHP certification standards in addition to those outlined in the ACA, including, but not limited to:– Requirements for a state-wide Service Area that expands provider coverage

throughout the entire state

– Network Adequacy standards that align with Medicaid and Department of Public Health standards

– Issuer-required Transition Plans that support continuity of care for consumers as they move from QHPs to Medicaid and vice-versa

– Quality Improvement Strategies, including a requirement that all Issuers participate, at the prevailing rate, in the Delaware Health Information Network (DHIN)

• In October, the Health Care Commission (HCC) conducted an open comment period, inviting stakeholders to provide input on the draft state-specific QHP Standards.

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Stakeholder Response to QHP Standards

HCC received input from 33 stakeholders, including:

• Mental Health Providers / Professionals (16)

• Medical Providers (5)

• Issuers (6)

• Professional Associations (2)

• Agents / Brokers (1)

• Research Groups (1)

• Community Partners (1)

• Pharmaceutical (1)

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Stakeholder Feedback on QHP Standards

• Feedback included a broad range of input regarding continuity of care, network adequacy, accreditation, plan levels, essential community providers and quality improvement standards

• The DOI, with support from the HBE project team, will develop a response to stakeholder feedback in the form of ‘frequently asked questions’ (FAQs), which will be posted to the HCC website in early December.

• The Essential Health Benefits FAQs will also be updated to address input related EHBs, such as Mental Health parity

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Summary of Stakeholder Feedback

• State should require transition plans for Medicaid plans as well as QHPs• The state does not have the authority within the QHP standards to address this; however,

the DHSS will explore transition plans for Medicaid plan Issuers with QHPs and update the HCC in the future

• State should add the clause ‘any able provider’ to both the Continuity of Care and Network Adequacy standards

• The DOI and the HCR workgroup feel that this would require separate legislation, and that the issue be explored by the HCC and considered as a standard in subsequent years.

• State should require QHPs to contract with federally qualified health centers (FQHCs) as an Essential Community Provider and adhere to the prospective payment system (PPS) rate.

• An additional clause has been added to the Network Adequacy standards

• Continuity of Care should not apply to individuals who voluntarily disenroll in a QHP, do not enroll in another QHP, but are still not eligible for Medicaid/CHIP.

• An additional clause has been added to the Continuity of Care standards

• State should add specific language regarding the number and types of providers required in the plans network to include Chiropractic, certain types of mental health providers (psychologists) and those that specialize in women’s health issues.

• The DOI and HCR workgroup feel that the existing federal and state standards sufficiently cover the broad range of providers.

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Summary of Stakeholder Feedback

• One Issuer recommended that the state follow the federal standard and require accreditation on product type by fourth year and not the third year.

• Since a majority of the Issuers who will participate are already engaged in the accreditation process, the DOI feels that three years is sufficient time

• One pointed out that there is no accreditation entity/process for dental insurers• Standalone dental issuers will be exempt from this standard. The state will look to HHS for

further guidance in future years.

• State should require each certified Issuers to offer at least one ‘Bronze” level plan on Exchange to promote more choice of cost-effective plans

• The DOI and the HCR workgroup agreed and will add this requirement to the state standards.

• One Issuer noted that ‘because there is no current ‘prevailing fee structure’ it may be unreasonable to adopt the requirement for Issuers to participate in the DHIN

• The prevailing fee structure of $0.78 PMPM is included in the DHIN’s approved 2011 business plan. However, since there is no dental plan information collected at this time, the standard will be modified to provide an exemption for issuers of stand-alone dental plans. The state will revisit this requirement in the future.

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Additions/changes to proposed QHP Standards

Network Adequacy—two additional standards• Issuers of stand-alone dental plans are exempt from the state’s network adequacy

standards for medical and mental health providers. However, Stand-alone dental plans must comply with SSA 1902(a)(30)(A), and assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.

• The Delaware Exchange requires that each health plan, as a condition of participation in the Exchange, shall (1) offer to each Federally Qualified Health Center (as defined in Section 1905(I)(2)(B) of the Social Security Act (42 USC 1369d(I)(2)(B)) providing services in geographic areas served by the plan, the opportunity to contract with such plan to provide to the plan’s enrollees all ambulatory services that are covered by the plan that the center offers to provide and (2) reimburse such centers for such services as provided in Section 1302(g) of the Patient Protection and Affordable Care Act (Publ. L.111-148) as added by Section 10104(b)(2) of such Act.

Accreditation• While all Issuers must comply with existing state and federal codes and regulations, Issuers

of stand-alone dental plans are exempt from the state’s Accreditation standard until such time as accreditation standards, entities and processes are available through federal guidance.

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Additions/changes to proposed QHP Standards

Plan Levels• Issuers certified on the Exchange will be required to offer at least one QHP at the

Bronze level, in addition to the Silver and Gold levels as required by the federal standard.

Quality Improvement • Issuers, with the exception of those who provide stand-alone dental plans only,

will be required to participate in and utilize the Delaware Health Information Network (DHIN) data use services and claims data submission services, at prevailing fee structure, to support care coordination and a comprehensive health data set as a component of state quality improvement strategy.

Stand-alone Dental Plans• All stand-alone dental plans must be compliant with Title 18, Chapter 38: Dental

Plan Organization Act

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HCC Decision Points

1. Delaware QHP Certification Standards• Approve proposed state-specific standards for certification of qualified

health plans offered and sold on the Delaware Exchange

2. Essential Health Benefit Benchmark plans• Select and approve the supplemental pediatric dental plan (FEDVIP vs.

Medicaid/CHIP)

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