2017 Molina Marketplace-OHIO Kahassai Tafese, Broker Channel Manager - - PowerPoint PPT Presentation

2017 Molina Marketplace-OHIO

Kahassai Tafese, Broker Channel Manager Marketplace – Eastern Region (OH) kahassai.tafese@molinahealthcare.com 614-623-8267

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Where We Are Nationwide

California California Illinois Illinois Texas Texas South Carolina South Carolina Ohio Ohio Michigan Michigan Florida Florida Washington Washington Wisconsin Wisconsin Utah Utah New Mexico New Mexico Puerto Rico Puerto Rico

New Jersey New Jersey West Virginia West Virginia Louisiana Louisiana Idah

• Idah
• Maine

Maine U.S. Virgin Islands U.S. Virgin Islands

MMS State Plans Both

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Healthcare Direct Delivery – Molina Medical & Hospital Management

Our approach to direct delivery is flexible and can accommodate changes in local market

• needs. Currently we own 26 clinics in 5 states, operate 3 county clinics in Virginia and

manage a hospital in Long Beach, CA.

Long Beach, CA (hospital ) Long Beach, CA (hospital ) California (20 clinics) California (20 clinics) Washington (1 clinic) Washington (1 clinic) New Mexico (1 clinic) New Mexico (1 clinic) Virginia (3 clinics) Virginia (3 clinics) Florida (2 clinics) Florida (2 clinics) Utah (2 clinics) Utah (2 clinics)

What We Do

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2016 Broker Performance

• Sold 68% of MP business
• Contributed $875M Annualized Premium
• Collaboratively solved for CMS 834 issues to ensure

accurate and timely commission payments

• Molina in the top 10 MP QHPs in the country
• Contributed to the lowest uninsured rate in US

history

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A Successful Molina/Broker Partnership

Marketplace Effectuated Membership as of Apr 25, 2016

• Source Data: QNXT, ASPE

Total Members as of: May 30th 2014 (End of 2014 Open Enrollment)

260,870

Total Renewed and Effectuated Members As Of 3/11/15

Nearly 85% binder/initial payment rate for MP2016! 23,219

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148% Growth from 2015

650K Members

25,383 77,618 56,771 18,719 142,765 66,026 3,722 11,580 247,079

Source Data: 2016 Disenrollment Report

2017 Regulation Update

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Licensure and Product Presentation

• Must have valid license to sell

insurance with State of Ohio

• Disclose:

– Licensed agent in Ohio – 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 following actions 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 Agent Broker Registration Status page on the CMS Enterprise Portal.

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Agreement Requirements

Agents Participating in…. Must Execute the following agreements Individual Marketplace

• Individual Marketplace General

Agreement

• Individual Marketplace Privacy and

Security Agreement

• Agents and brokers who complete Individual Marketplace training will only be

able to execute the associated Agreements on the MLMS after completing the required training modules and exams.

• Agents and brokers must read and accept the terms of the required Agreements

in order to become a registered FFM agent or broker.

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2017 Open Enrollment and Re-determinations

• November 1, 2016: Open Enrollment starts — first day you can enroll in a

2016 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 Special Enrollment Period.

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2017 Existing Member Notifications

• Between Oct. 1- Nov. 15, formal renewal letters will be sent advising

existing enrollees of premium and plan changes existing.

• All enrollees who need to update their eligibility information for 2017 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 formal

notification 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 identical to 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 in the same plan for 2016, but APTC and CSR will end 12/31/15.

• Enrollees who didn’t authorize the FFM to obtain updated income

data will be renewed in the same plan for 2017, but APTC and CSR will 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 New Plan 11/1/16 - 12/15/16 1/1/2017 12/16/16 - 1/15/17 2/1/2017 1/16/17 - 1/31/17 3/1/2017

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Special Enrollment Periods

Regardless of whether you purchase insurance through the exchange or off-exchange, the annual open enrollment window applies. Outside of Nevada, you cannot enroll

• utside 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 to your move).

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4 Additional Special Open Enrollment Triggers

• Individual plan renewing outside of the

regular open enrollment. HHS issued a regulation in late May 2014 that included a provision to allow a special

• pen enrollment for people whose

health plan is renewing – but not terminating – outside of regular open enrollment.

• Becoming a United States citizen (this

qualifying event only applies within the exchanges – carriers selling coverage

• ff-exchange are not required to offer a

special enrollment period for people who gain citizenship or lawful presence in the US).

• An error or problem with enrollment (or

non-enrollment) that was the fault of the exchange, HHS, or an enrollment assister.

• Employer-sponsored coverage reducing

benefits such that it no longer provides minimum value, or becomes unaffordable (defined as requiring the employee to pay more than 9.66 percent of income for just the employee’s portion of the coverage in 2016).

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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 insurance

carriers also generally require proof of eligibility when people enroll off-exchange during a special enrollment period.

• If you experience a qualifying event and wish to enroll in a plan during your special

enrollment period, be prepared to provide documentation of the qualifying event.

Molina Healthcare of Ohio Network Operations

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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 – 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 – 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)

Ohio Health Insurance Marketplace

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2017 Marketplace Product -

Enclosed –

• 2017 Product Priorities
• Product Expansion and Portfolio changes
• ACA, EOC & Administrative Changes
• Plan Design Changes - Applied Across Coverage
• Plan Design Changes
• New Portfolio For 2017
• State Specific Revisions

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Market Expansion for 2017 – Ohio

• Expanded Marketplace County Footprint In Ohio:

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Our Mission Remains -

To provide quality healthcare services to people receiving government assistance

2017 Product Priorities –

• 1. Retain and Grow Membership in our current markets
• 2. Retain our FFM product portfolio with minimal changes to support

retention

• 3. Add 2017 CMS Standardized Options Product Offering in Specified

Markets

• 4. Where possible, address financial barriers to obtaining healthcare

2017 Product Priorities -

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Molina Marketplace – 2017 Plan Highlights

Overall – We continue to be very excited about our renewal portfolio

• a. With minimal changes to current plan cost shares, to promote retention and minimize

impact on pricing position

 Tweaks only to OOPM, Deductible, Emergency Room or Rx to maintain required Actuarial Value.

• b. Bronze Plan Deductible Positioning will support better access to care

 This high Deductible plan, now waives the Deductible for all Primary Care

• ffice visits, Other Practitioner office visits, Mental Health office visits, and

Substance Abuse office visits. This improves member access to the most frequently 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 Plan Design Features

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2017 Molina Plan Design Changes

▲= Deductible Applies Other Practitioner = Certain specialties such as Midwife, Physician Assistant, Nurse Practitioner

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2017 Molina Plan Design Changes

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2017 Molina 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”

• CMS Standard Silver Plans – Benefit Design Variance

Silver Plan Benefit Driver Molina Options Silver Plans Molina Renewal Silver Plans Silver 250% FPL Deductible Higher Lower OOP Max Higher Lower PCP Higher Lower SPEC Higher Lower Coinsurance Lower Higher Generic Rx Even Even Silver 200% FPL CSR Deductible Higher Lower OOP Max Even Even PCP Higher Lower SPEC Higher Lower Coinsurance Lower Higher Generic Rx Even Even Silver 150% FPL CSR Deductible Higher Lower OOP Max Lower Higer PCP Even Even SPEC Lower Higher Coinsurance Even Even Silver 100% FPL CSR Deductible Higher None OOP Max Even Even PCP Higher Lower SPEC Higher Lower Coinsurance Lower Higher Generic Rx Higher Lower

Comparing Silver Plans: Molina Options plans have:

• Higher Deductibles, PCP and

Specialty Copays, than our Renewal Portfolio

• But allow for plan choice,

determined on Individual need

• Allow you more flexibility
• ptions 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

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Molina Marketplace – 2017 State Specific Revisions

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Molina Marketplace in Ohio 2017 Product Changes

 Expanded into 2 New Counties  New Standardized Options plans  Gender Reassignment Surgery covered  PA list updated  Sleep studies are explicitly covered  Continuity of Care language updated  Balance Billing: Molina must negotiate and pay the balance.  Non-routine non-emergency transport is covered (e.g., Hospital to Hospital)  New language support (taglines and phone support)  Delete requirement for Subscriber to provide proof of child disability for eligibility of dependent over age 26  Preventive Services list expanded  For a chronic condition, Molina will honor a PA of an approved drug for 12 months  Molina will allow retrospective claim review for Medical Necessity, in some cases  Dialysis may include the supportive use of an artificial kidney machine.  If coverage terminates while Member is in a hospital, Molina will continue coverage

2017 Pharmacy Update and Prior Authorizations

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Pharmacy Highlights

1. 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 $0 copay

 Helps members know which prescriptions are No Charge

4. Expedited Review for Non-Formulary Drugs

 Decision must be provided within 24 hours for standard requests and within 72 hours for urgent requests  Improves member access to non-formulary drugs

“Ask your doctor if Molina is right for you”

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Pharmacy: Prior Authorizations

• Drugs requiring PA will be

notated “PA” in the formulary listing.

– Any drug not listed on the formulary would require a PA.

• Physician must submit a PA form

to Molina

– The inability of the prescriber to provide the required information is the biggest cause for delay in receiving approval on a PA request, and may actually lead to a denial.

• It takes ONE (1) day on

average for Molina to respond with Approval or Denial.

– Federal law requires a decision within 72 hours for a standard request and within 24 hours for an expedited request – Molina Marketplace does not provide partial supplies of

• drugs. In urgent situations

(defined by the nature of the member’s medical condition), the PA requests are reviewed in a 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 the PA requirements may be, etc.

• Can the agent find potential “Like” drugs? For example, Molina may cover a different

brand or generic, but how does the agent/member know which alternative drugs are covered?

• 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).

My Molina

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• 24 hours once application is submitted successfully, Molina will be

able to view in our internal member database.

• Member will be able to create an account on Mymolina.com or

mimolina.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 onto the Molina Direct or Healthcare.gov site to attach your information to the application.

My Molina Site

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Reminder: Cannot print ID till effective date.

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Ways To Pay

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 Information

Welcome 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 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 2

Note: 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: mpbrokercareteam@molinahealthcare.com

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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, Director Rhonda Clark-Manager Tom Grady, Supervisor Broker Services Ilse Galaz, Supervisor Contracting & Onboarding Summer Brown, Supervisor Commission Recon

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BSU (Broker Support Unit)

Phone #: 1.855.885.3179

Broker Services - # 1

mpbrokersupport@molinahealthcare.com

Broker Care Team- # 2

mpbrokercareteam@molinahealthcare.com

Commission Team- # 3

MPBrokercommissioninquiry@molinahealthcare.com

Contracting Inquiries - # 4 MPBrokerContracting@molinahealthcare.com Monday through Friday – 8:00 AM to 5:00 PM (CST)

Hours of Operation

Non-Open Enrollment Period Open Enrollment Period Feb 1 thru Oct 31

Monday thru Friday 7:00am to 6:00pm MST

Nov 1 to Jan 31 Monday thru Friday 6:00am to 7:00pm MST Saturdays 7:00am to 4:00 pm MST

Molina’s Commitment

• Significant infrastructure investment to support Marketplace Product Line
• Advocating for a stronger sustainable risk pool
• Developing a robust advocacy initiative with CMS
• Improving validation process for SEP
• Redefining risk transfer process
• Molina’s Marketplace is Molina’s Medicaid expansion product within states

that have not expanded

• Target audience is extremely price sensitive, further supporting Molina’s intent

to be a low cost premium

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Why Sell Molina?

• Deductible applies to OP Facility Services and IP Services
• nly.(Silver & Gold Plans)
• Molina does not rate up for smokers
• Reoccurring payment and PCP at time of enrollment
• HMO but no referral needed for specialist
• Network of hospitals and providers
• Exceptional Broker Support Unit and very broker focused

Questions