Maryland Health Benefit Exchange Web-Based Entities(WBE) Advisory - - PowerPoint PPT Presentation

A service of Maryland Health Benefit Exchange

Maryland Health Benefit Exchange

Web-Based Entities(WBE) Advisory Committee Introductory Meeting July 25, 2013 4:00-6:00 pm UMBC Tech Center 1450 S. Rolling Road, Baltimore, MD, 21229

Agenda Agenda

• Introduction of Chair, supporting staff and members;
• Overview;
• Description of WBE Advisory Committee charter;
• Review of WBE federal regulations and guidance;
• Review of MHBE WBE activity to date;
• Description of producer authorization;
• Update on partnerships in the small group market;
• Description of IT system;
• Committee discussion; and
• Discussion of next meeting.

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Introductions

WBE Advisory Committee

• Dr. Joshua Sharfstein, Chair, MHBE Board of Trustees

Jim Bendel, President, Potomac Basin Group Associates Kimberly Cammarata, Director, HEAU John Condrat, Manager, Extend Health Vickie Cosby, Senior Director, Consumer Direct Sales and Training, CareFirst BlueCross Blue Shield Samuel C. Gibbs, III, SVP and President of Government Services, eHealth Mary Lou Fox, Maryland Women’s Coalition for Health Care Reform Melanie C. Green, Health Services Manager, Aetna, Inc. Wesley Mace, Vice President, Kelly & Associates Insurance Group, Inc. Megan Mason, Special Assistant for Health Care Reform, MIA Tara Pellet, Consultant, Allied Resource Management – A TriBridge Partners company

• Dr. Patrick Richard, Community Alliance For Health Care

Coverage & Access WBE Advisory Committee Members:

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Overview of Actions to Date

Board Action to Date March 12th: The MHBE Board recommended seeking public comment on the policy, technical and logistical issues of partnering with a WBE. May 14th: Based on the response to the request for public comment the MHBE Board created the WBE Advisory Committee. July 8th: The MHBE Board approved members for the WBE Advisory Committee. Action Since Last Board Meeting:

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Description of WBE Advisory Committee Charter

WBE Advisory Committee Charter To collect a Maryland-specific perspectives from key stakeholders to inform the Board on whether and how to partner with WBEs as the MHBE moves forward with implementation. These perspectives will help ensure that any partnership enhances Marylanders’ shopping experience while protecting consumers and the integrity of the market. Purpose:

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WBE Advisory Committee Charter Take testimony from subject matter experts on WBEs; Receive public comment on the key issues around partnering with WBEs; and Facilitate dialogue between members in order to advise the Board on whether and how to partner with WBEs. Objectives:

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WBE Advisory Committee Charter Expert and public testimony will be taken on a specific topic; Committee dialogue will be facilitated; MHBE Staff Recommendations will be developed; and MHBE Board will determine next steps.

The WBE Advisory Committee meetings will adhere to the following framework:

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WBE Advisory Committee Charter

Consumer Protection: – Unique WBE consumer protections beyond the minimum requirements set out in the final federal Exchange rule; – Additional WBE services, such as phone support, which would enhance the consumer shopping experience; and – Training standards for WBE producers and non-producer personnel. Contractual Feasibility: – Criteria to determine the number of WBEs participating in the state; – Assessment of the staffing needs of the MHBE in performing WBE

• versight and enforcement;

– Coordinated enforcement process between relevant state agencies; and – Necessary components of an agreement between a WBE and the MHBE. Technical Feasibility: – Necessary IT testing and integration.

Topics:

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Review of WBE Federal Regulations and Guidance

Federal Law

The March 2012 federal Exchange rule provides for the use of WBEs: A WBE cannot independently perform eligibility determinations as part of enrollment; and In order to enroll in a QHP, an individual must complete the streamlined application described in 45 CFR §155.405.

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Federal Law

March 2012 federal Exchange rule provides that a WBE must: Meet all standards for disclosure and display of QHP information; Provide consumers the ability to view all QHPs offered through the Exchange; Not provide financial incentives, such as rebates and giveaways; Display all QHP data provided by the Exchange; Maintain audit trails and records in an electronic format for a minimum of ten years, and Provide consumers with the ability to withdraw from the process and use the Exchange Web site at any time. 45 CFR §155.220(c)(3)

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Federal Law

On May 1st CCIIO issued FAQs on the role of agents, brokers and web-brokers in health insurance marketplaces, which indicated: SBEs may work with Web-brokers; and CMS is developing the capability to support integration between a web- broker’s website and the FFE’s website using secure redirect and application programming interface mechanisms. In addition to the minimum requirements set out in the final Exchange rules (45 CFR § 155.220(c)(3)), the FAQs indicated that a web-broker partnering with the FFE must: – Securely transmit and receive QHP, eligibility and enrollment information between the FFE and the web-broker; – Meet all existing and future HHS privacy and security standards; – Authenticate consumer identification; – Comply with State appointment requirements; – Refrain from steering consumers to specific plans; – Disclose compensation; – Offer a QHP shopping experience free of non-QHP advertising; – Provide quality information on each QHP; and – Provide all required disclosures.

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Federal Law

On June 19th CCIIO published a program integrity rule, which proposed: To limit a Web-broker’s obligation to disclose and display QHP information to all the information provided by the Exchange or directly by the issuer; In situations where a Web-broker is unable to display certain QHP information, the Web-broker must display a link to the Exchange Website; Web-brokers in the FFE must prominently display language notifying consumers that their Website is not an FFE Website, might not display all QHP data available on the Exchange Website; the Web-broker has entered into an agreement with HHS, and the Web-broker agrees to comply with all federal standards; and Web-brokers who make Websites available to other agents or brokers must require that the agents or brokers using the Web-broker’s Website enter into an agreement with the Web-broker indicating they will comply with federal standards and provide to HHS a list of those agents and brokers.

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FFE Participation

As noted in CCIIO’s FAQs, WBEs will be permitted to partner with FFEs: CCIIO circulated a proposed WBE agreement and the final version will soon be published. Primary areas of the agreement included:

– Privacy and security standards regarding Personally Identifiable Information; – An expansive list of services to be provided by the WBE; and – Strict termination procedures, including a “Habitual Default" default provision.

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Review of MHBE WBE Activity to Date

Request for Public Information March 12th: The MHBE Board recommended seeking public comment on the policy, technical and logistical issues of partnering with a WBE. March 16th: A request for public information (RFI) was posted on the MHBE website soliciting public comment on WBEs in the areas of: – Policy (Consumer Value and Protections); – Technology (Access to Maryland Health Connection); and – Logistics (Participation and Enforcement). March 29th: The RFI comment period closed and the MHBE received comments from 37 individuals representing 41 different interest and organizations. Action to Date:

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Public Comments

Additional consumer protections; Licensure and training requirements; Levels of technical integration; Number of suggested WBE partners; Possible enforcement frameworks; and Potential contractual provisions.

Comments provided numerous suggestions, including:

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WBE Letter of Intent

MHBE received responses from eighteen different

• rganizations, including:

– Several nationally based WBEs; – A TPA; – A Wholesale distributor; – Several brokerage firms; – An individual producer; – A Non-profit organization; – Several IT companies; and – An independent contractor.

Each category of organization had varying degrees of experience and sophistication in providing web-based services.

June 11th-July 1st MHBE Sought Letters of Intent from Entities Interested in Partnering with the State as WBE:

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A service of Maryland Health Benefit Exchange

Producer Authorization Process July 25, 2013

Producer Operations Guiding Principles Maryland Health Connection

– Individuals & Families – SHOP

Producer Authorization

– Requirements to Apply – Authorization Application – Required Training – Authorization Notification – Authorization Expiration

Topics Under Discussion Ways to Get More Information

Today’s Agenda

Producer Operations – Guiding Principles

The Maryland Health Benefit Exchange will use the following guiding principles to establish its approach to working with insurance producers:

• Maryland Health Connection will supplement the current

market not replace it so that all Marylanders without health insurance have access to affordable insurance options.

• Consumers should have broad access to resources that will

allow them to make informed decisions about health care insurance options.

• Consumers should be able to obtain advice from

knowledgeable and trustworthy sources.

• Insurance Producers are instrumental in helping consumers

understand all benefits that are available.

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Producer Operations – Guiding Principles

Maryland Health Connection – a service of the Maryland Health Benefit Exchange

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Individuals and families have access to Medicaid and commercial plans Offers tax subsidies and cost sharing reductions to individuals and families to make commercial plans affordable

– Only place individuals can access subsidies – Federal government will pay a portion of costs for health insurance for people who earn up to 400% of FPL – Cost sharing reductions are available to individuals under 250% of FPL

Individual Open Enrollment: October 1, 2013 - March 31, 2014

– Coverage Effective: January 1, 2014 – Annual open enrollment occurs starting in October of each year

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Maryland Health Connection Marketplace for Individuals & Families

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Maryland Health Connection will have a Small Business Health Options Program (SHOP) for small businesses and their employees -- a competitive private health insurance marketplace Small businesses with up to 50 employees may participate

– In 2016, the ACA modifies the definition of small group to 100 employees SHOP supplements the existing market…SHOP does not replace it!!

– Small employers will still be able to purchase insurance outside of the SHOP

SHOP Open Enrollment: January 1, 2014

– Coverage Effective: March 1, 2014 – Annual open enrollment is based on the renewal date of the small business

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Maryland Health Connection Marketplace for Small Businesses

Producer Authorization: The 3-Step Process

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Licensed Health Producers can apply as long as they meet the following criteria:

– Holds a current license that qualifies the producer to sell health benefits in Maryland – Is in good standing with no outstanding consumer complaints – Maintain a sufficient level of errors and omission coverage as required by carriers – Not excluded from participation in federal health programs – Not debarred from State contracts – Have completed MHBE required training and authorization process – Agree to present all plans from all participating carriers and disclose appointment status to consumers – Agree to privacy and security standards established by the MHBE – Agree to work cooperatively with Connector Entities/Navigators, as applicable – Agree to immediately report concerns or complaints from employers, employees

• r individual consumers

– Agree to complete re-training education requirements.

Both resident and non-resident producers are eligible to apply

Criteria for Applying

Producer Authorization

Every licensed producer who wants to discuss plans offered on Maryland Health Connection with individuals and small businesses must complete the 3 steps of authorization Out of state exchange authorization will not be accepted as a replacement for Maryland authorization

Requirements

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Producer Authorization

• 1. Submit the

MHBE Application

• 2. Complete

MHBE Training

• 3. Receive MHBE

Authorization

Steps to Producer Authorization

Producer Authorization

MHBE has a 3-step process for Producer Authorization. Producers must complete all 3 steps in order to sell plans offered through Maryland Health Connection.

Application will be available on-line at www.marylandhbe.com. Download the MHBE Producer Attestations Fill out the Application Upload the required documents

Application Process

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Producer Authorization: Step One

First Name, Middle Initial, Last Name, Suffix Gender Employer/Company Name Employer/Company Tax ID NPN (National Producer Number) Maryland Insurance License Number (NUMBERS ONLY) Maryland Insurance License Expiration Date Errors & Omissions (E&O) Coverage Expiration Date Business Address Phone Email Website Program Type

– Individual Exchange – SHOP – Both Individual and SHOP

Appointments (checkboxes) Captive Producers Only

– Are you a Captive Producer?

Application Fields

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Producer Authorization: Step One

Maryland Insurance License Errors & Omissions Declaration Page Signed MHBE Producer Attestations

Application Document Uploads

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Producer Authorization: Step One

Remember to check your information before it is submitted

– Individuals and small businesses will find you in Maryland Health Connection from the name and address you provide – Carriers will link you in their systems based on the NPN and tax ID number that you put on the application

A member of the Producer Operations team will reach out to you via email if there is any missing information

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Producer Authorization: Step One

Application Reminders

The MHBE will begin to offer training sessions for producers in August 2013

– Only training offered by MHBE will be accepted for authorization – Details of the training are being developed – The training sessions will be up to eight hours and offered in a conference format

MHBE is working to determine if CE credits can be given for Maryland Health Connection Producer training Information on available training sessions will be posted on www.MarylandHBE.com on the Insurance Producer page

Training

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Producer Authorization: Step Two

The first round of notification will be going out in September MHBE will provide a Certificate of Authorization to authorized producer Authorized producers will be emailed additional instructions on how to set up their account All Authorized Producers will appear on Maryland Health Connection

Notification of Authorization

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Producer Authorization: Step Three

MHBE will be reaching out to producers during the year when their license is about to expire or when their E&O Coverage is about to expire In order to remain authorized, the producer will need to submit their upload their new MD License & E & O declaration page

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Mid Year Documentation Required

Producer authorization expires two years after the date it is issued

– MHBE will notify authorized producers 60 days before expiration

Producer Authorization Expiration

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Producer Authorization Expiration

Carrier appointments are NOT a pre-requisite of producer authorization. Interim procedures provide rules for carriers when appointing producers:

– A carrier must appoint an authorized producer within 10 business days of receipt the request from the producer – A carrier must appoint every authorized producer

• unless reasons specified under 31112(e)(1), Annotated Code of Maryland

– A carrier can not deny appointment based on production volume – A carrier can not impose a production requirement – A carrier must allow authorized producers to discuss all Maryland Health Connection plans with or without an appointment – A carrier must provide a basis for denial to the authorized producer within 10 business days – Dispute resolution will be managed by the MIA

• While the dispute is being reviewed by the MIA, the producer can continue to sell and

enroll individuals and small businesses

– A carrier can limit the scope of an appointment to only Maryland Health Connection – A carrier must provide information on their producer register upon request of the MHBE

Carrier Appointments

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Producer Appointments

Carriers will continue to be responsible for compensation of producers that sell plans on Maryland Health Connection. Carriers will continue to develop their own models of compensation for producers. Compensation models must not result in the disruption of consumers’ access to qualified plans, steering of consumers away from appropriate insurance offerings,

• r threaten the viability of Maryland Health Connection.

Carriers are expected to develop equivalent compensation and incentives for sales inside and outside of the state-based exchange. Carriers are required to collect and maintain producer compensation data including agreements, policies, procedures, programs and other information regarding producer compensation. Carriers must provide this information to the Maryland Insurance Administration upon request.

Producer Compensation

Producer Compensation

Company / Agency Search Book of Business Management Tools Support Staff Functions

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Topics Under Discussion

Rebecca G. Bayne – Manager, Producer Operations Christopher Yeiser – Business Operations Specialist Becky Smith – Business Operations Specialist

Email us at Producer@MarylandHBE.com

The Producer Operations Team

Producer Support Model

Ways to Get More Information!

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Online Resources

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Sign Up for Email Updates Sign Up for Text Updates: Text “Connected” to 69302 Get information on insurance resources available to help now Plans Available Individuals – October 1, 2013 SHOP – January 1, 2014

MarylandHealthConnection.gov MarylandHBE.com

Producer Training & Authorization Information Meeting Information RFP Announcements Job Information

A service of Maryland Health Benefit Exchange

Partnerships in the Small Group Marketplace July 25, 2013

An important feature of the existing Maryland small group market is the key role Third Party Benefit Administrators (TPAs) play in the sale, enrollment, and financial administration of small group health plans The electronic data processing capabilities of these TPAs in Maryland is mature and health insurance carriers, producers and employers in the state rely on these TPAs to perform many administrative functions. TPAs in Maryland typically provided a benefit administration beyond the scope of the medical and dental and provide additional benefits to employers such as life, disability, and even payroll management.

TPAs in Maryland’s Small Group Market

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As part of the Small Business Health Options Program (SHOP), TPAs can partner with the Maryland Health Benefit Exchange to perform several business functions including:

– Qualified health plan comparison and selection by employers and employees – Administration of enrollment and eligibility changes – Premium billing and collections

TPAs must be certified by MHBE to perform administrative functions. To be eligible for the TPA Certification program, a Third Party Administrator license that is current and in good standing with the Maryland Insurance Administration (MIA) is required

TPA SHOP Certification Program

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TPA Services

Program 1: SHOP Alternate Online Market Place and Back Office Services – The TPA will have their own system that will replicate the Maryland Health Connection

• nline shopping flows

Program 2: SHOP Back Office Administrative Services – The shopping experience will take place in Maryland Health Connection and the TPA will be responsible for back-office administration in their own system. Program 3: SHOP Online Administrative Services – Both the shopping experience and the back

• ffice administrative activity take place in

Maryland Health Connection.

Three distinct programs allow third party administrators choose how they want to participate in the SHOP Exchange TPA Program Options

Program 1 Program 2 Program 3

Organizations that wish to become certified as TPA business partners with MHBE must be approved through the MHBE Certification Process. The certification process is under development in cooperation and will consist of four components:

1) TPA Application Package 2) Systems & business operations validation 3) Training 4) Certification from MHBE

The application package and agreements will be available on the MHBE website in July 2013.

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TPA Certification Program

July

• TPA Certification

Application Package Posted on www.marylandHBE.com

• TPAs will have 30 days to

respond

August

• TPAs Submit Application

Package to MHBE

September

• MHBE Notifies TPAs of

Application Status

• Certification Process Begins

October – December

• TPA System & Business

Operations Validation

• Integration Testing
• Training

January

• SHOP TPAs Go Live

TPA Certification Program - Launch Schedule

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TPA Services

MHBE will consider two key criteria in evaluating the applications and planning for implementation timing

1. Capabilities of the TPA

• TPA License issued by the MIA
• Carrier Integration
• System Capabilities
• Operations Capabilities
• Producer Engagement
• Employer Engagement
• Plan for Increasing Participation in the SHOP

1. Volume of Applicants

• MHBE Resource Availability/Backlog Review

MHBE Evaluation Criteria

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TPA Services

For questions on the information contained in this presentation, please contact: Tequila Terry Director, Plan & Partner Management Maryland Health Benefit Exchange Email: Tequila.Terry@maryland.gov www.MarylandHealthConnection.gov

Thank you!

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Description of IT System

MHBE Business Functions

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High Level Technology Architecture

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Noridian-Provided Functionality

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The system is designed as an integration of Commercially Off the Shelf (COTS) products, that are being integrated and configured to meet Federal and State requirements. The key building blocks of the solution include:

• Cúram - a software product that has existing

and planned features to support requirements for Eligibility and Enrollment.

• Connecture - a software product that has

existing and planned features that support requirements for Plan Presentment and Enrollment.

• EngagePoint - the systems integrator for the

COTS solutions, using the EXACT Service Oriented Architecture (SOA) integration product along with the Financial Management Solution

• Noridian - provides project management
• versight and the EXACT SOA product.

Customer Eligibility and Enrollment Flow

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Welcome to Maryland Health Connection Login Application Tax Credit Determination Plan Shopping Initial Payment Collection Congratulations! You’re Covered!

What the customer sees…. What happens behind the scenes….

Customer Account Created Customer Demographic Data Captured Eligibility Determined Enrollment File Created Bill Created Federal Data Hub Confirmation of Enrollment from Carrier Carrier receives 834, 820, cash transfer Carrier Processes Enrollment

MHBE / HIX HHS / CCIIO Carriers Tivoli Curam Exact Exact BillSpan Connecture

Initial Bill Presentment

Payment Processed

BoA / FMIS

62 Integration Layer: EXACT “Submit Enrollment” service “Send Enrollment” service Shared Services WTX Translation B2B intgr. 62

EngagePoint Financials Connecture Curam

Carrier 1 Carrier 1 Carrier 4 Carrier 2 Carrier 3 Carrier 5

Audit Document Mgmt. WTX Validation HIPAA Pack Collect Enrollment Data IDS Prepare Enrollment Data

Carrier 1 Carrier 4 Carrier 2 Carrier 3 Carrier 5

Carrier Aggregation Fuse Router Get Enrollmt Data

1 2 4 3 5 6 7 8 13 9 10 11 12 14 15

Enrollment Service (Behind the Scenes)

Working with 3rd Parties – The TPA SHOP Model

Program 1: Alternate Online Marketplace: Certifies TPAs or other qualified organizations to establish an online shopping website where employees can compare and enroll into medical, dental, and vision plans per the parameters specified by the employers in conjunction with program 2 services. Program 2: SHOP Back-Office Administrative Services: Certifies TPAs to use their systems for account set-up, employer premium aggregation, billing, and collections, employer enrollment changes, and payments to carriers. Program 3: SHOP Online Administrative Services Provider – Certifies TPAs to use Exchange systems to support employers and employees in both plan set-up and selection as well as back-office administrative services such as billing and collections support and managing eligibility and group roster changes.

Three distinct programs allow third party administrators choose how they want to participate in the SHOP Exchange

Program 1 Program 2 Program 3

Technology Integration with TPAs

Program 3 Program 2 Program 1

Differences between Individual Exchange and SHOP Multiple assistance paths including Medicaid, Advance Premium Tax Credits (APTC), and Cost Share Reductions (CSR) Single Open Enrollment Period with multiple exceptions for Special Enrollments in the Individual Exchange for QHPs Initial Billing in Individual Exchange vs. Ongoing Billing in SHOP Integration with Federal Data Services Hub for:

– Identity Proofing – Lawful Presence / Citizenship – Income (Federal Tax Information) – Eligibility for Medicaid, APTC, and CSR

Special rules for bill payment grace period

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Individual Exchange Includes a Greater Level of Rules and Regulations than SHOP

Last but not Least: Privacy and Security Considerations Minimum Acceptable Risk Standards for Exchanges (MARS-E)

– Federal Information Security Management Act (FISMA) – Health Insurance Portability and Accountability Act (HIPAA) – DHHS Final Rule on Exchange Establishment Standards and Other Related Standards under the Affordable Care Act, 45 CFR Parts 155, 156, and 157 – Internal Revenue Code (IRC), 26 U.S.C. §6103

Specific Privacy and Security Rules for

– Personally Identifiable Information (PII) – Protected Health Information (PHI) – Federal Tax Information (FTI)

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Committee Discussion

Public Comment

Next Meeting

Next Meeting Topics: Federal consumer protections; Proposed consumer protections received through public comment; Consumer protections necessary to ensure consumer shopping experience; Required additional consumer support services; Disclosures and conflict of interest requirements; Relationship to other licensees, such as the consolidated service center, connectors and authorized producers; How Medicaid enrollees will be handled; and Enforcement, including authorization, oversight and training. Next Meeting: Consumer Protections and Additional Required Services.

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Next Meeting

August 2nd 1:00-3:00 pm UMBC Tech Center 1450 S. Rolling Road Baltimore, MD, 21229 Time and Location:

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