Achieving Continuity of Coverage in the Exchange Commonwealth Fund Alliance for Health Reform

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

2. Agenda Achieving Continuity of Coverage in the Exchange | May 20, 2011

3. Responsibility • Health Benefit Exchange • Health Benefit Exchange • Health Benefit Exchange • Medicaid / CHIP • Health Benefit Exchange • Individual Plan • Individual Plan • Function • Application enters exchange • Data collected to support application (i.e., citizenship, residency, income) • System screens based on data and determines subsidy level • Consumer is notified of his/her subsidy level • Based on subsidy level, consumer is directed towards a selection of plans • If Medicaid/CHIP, consumer is further directed • Consumer chooses plan • Consumer is notified that selection has been received • Selected health plan receives enrollment data • Consumer is enrolled and coverage is activated * Data sharing for the purposes of determining eligibility for additional benefits. Continuity in Eligibility & Enrollment Achieving Continuity of Coverage in the Exchange | May 20, 2011

4. Coverage Options in the Exchange • State Health Subsidy Programs in ACA • Medicaid for individuals < 139% FPL • CHIP for children in families between 139% FPL and state ceiling • Basic Health Program for individuals between 139% and 200% FPL (optional) • Qualified Health Plans (QHPs) offering products for individuals with incomes between 139% and 400% FPL • QHPs offering non-subsidized products Achieving Continuity of Coverage in the Exchange | May 20, 2011

5. Continuity of Coverage in the Exchange • Goals • Facilitating transitions • Leveraging buying power Minimal Integration Maximum Integration • Strategies • Contracted Plans • Marketing Rules • Quality Strategies • Reporting Requirements • Benefits • Provider Networks • Basic Health Program Achieving Continuity of Coverage in the Exchange | May 20, 2011

6. MMC / BHP BHP / QHP MMC / BHP / QHP Contracting Options Medicaid Managed Care/Basic Health Program Basic Health Program/Qualified Health Plan Achieving Continuity of Coverage in the Exchange | May 20, 2011

7. Certification Requirements Across Plans Federal Standards for QHP Certification Licensed insurer Provides essential benefit package Charges same premium in and out of Exchange Network ensures sufficient choice of providers Inclusion of “essential community providers” Accreditation on clinical quality measures Provision of information on quality measures Implementation of QI strategies Utilization of a standard format for presentation of benefits Utilization of a uniform enrollment form Marketing requirements Federal Standards for QHPs State Standards for Commercial Plans State Standards for MMC Plans Achieving Continuity of Coverage in the Exchange | May 20, 2011

8. Quality Strategies Across Plans Federal Standards for QHPs Increased reimbursement or other incentives for and reporting of Implementing activities to improve health outcomes, including use of medical homes Implementing activities to prevent readmissions Implementing activities to improve patient safety and reduce medical errors Promotion of wellness and health Reduction of disparities As of Jan. 2015, a QHP may only contract with a hospital that Utilizes a patient safety evaluation system Assures patients receive comprehensive plan for hospital discharge Implements a health care QI program Federal Standards for QHPs State Standards for Commercial Plans State Standards for MMC Plans Achieving Continuity of Coverage in the Exchange | May 20, 2011

9. Consumer Information and Reporting Requirements Federal Standards for QHPs Provide information in plain language on: Claims payment policies Periodic financial disclosures Data on enrollment and disenrollment Data on denied claims Data on rating policies Information on cost sharing Information on enrollee rights Federal Standards for QHPs State Standards for Commercial Plans State Standards for MMC Plans Achieving Continuity of Coverage in the Exchange | May 20, 2011

10. Benefit Options ** ** ** * Subject to HHS approval ** Optional Achieving Continuity of Coverage in the Exchange | May 20, 2011

11. BHP: An Affordable Bridge Between Medicaid & QHP? • Citizens and lawful immigrants with incomes between 139% and 200% of FPL who would otherwise access coverage through Exchange. • Lawful immigrants with incomes < 139% of FPL who are not eligible for Medicaid • States must undertake procurement • States receive 95% of federal premium subsidies plus offset for out-of-pocket (OOP) • Premiums paid by enrollee cannot cost more than the second lowest-cost silver plan, with OOP at or below platinum or gold levels. • BHP eligible individuals cannot purchase QHPs Achieving Continuity of Coverage in the Exchange | May 20, 2011

12. For More Information Deborah Bachrach Special Counsel Manatt, Phelps & Phillips, LLP 7 Times Square New York, New York 10036 (212) 790-4594 dbachrach@manatt.com Achieving Continuity of Coverage in the Exchange | May 20, 2011