State to State Exchange on Health Insurance Exchanges

State to State Exchange on Health Insurance Exchanges
Webinar: November 22, 2010
State to State Exchange on
Health Insurance Exchanges
Supported by the Health Resources and Services Administration
Monday, November 22, 2010
This event will begin at 1:30pm Eastern
Please hold until Anne Gauthier starts the conference
The audio portion of this web event can be accessed by dialing
800-269-3762

Agenda
1:30-1:35pm Welcome
Anne Gauthier, Senior Fellow, NASHP
1:35-1:50pm Overview of Key Exchange Design Issues
Sonya Schwartz, Program Director, NASHP
1:50-2:35pm Interview About Current Exchange Thinking
Trish Riley, Director, Maine Governor’s Office of Health Policy
and Finance
Jane Cline, Commissioner, West Virginia Office of Insurance
2:35-2:55pm Question and Answer with Audience
2:55-3:00pm Wrap Up

Overview of Key Design Issues
Sonya Schwartz
Program Director, NASHP

Design Issue #1: Overall Vision
• Sub-state, state,
regional, or federal
option?
• One exchange or two
(one for small business,
one for individuals) ?
• Allow all plans to
participate or select
plans that meet certain
standards?

Design Issue #2: Governance
• New or existing state
executive branch
agency under the
Governor?
• Quasi public entity
governed by a Board?
• State-established non-
profit?

Design Issue #3: Eligibility and
Enrollment Systems
• One system or interface that
links separate systems?
• Who will develop it and
where will it sit?
• How does it link to
Medicaid, CHIP and other
programs?
• How do states develop the
information technology
resources?

Design Issue #4: Tools to Achieve
Affordability
• Exchange as market
organizer or active
purchaser?
• Rewarding or
encouraging high value
plans or delivery system
reforms?
• Use tools to prevent
adverse selection?

Design Issue #5: Stakeholder Engagement
• Use the governing entity
as a tool for involving
stakeholders?
• Hold public hearings on
major decisions?
• Opportunities for public
comment on proposals?
• Feedback loop?

Today’s Expert Panel
Trish Riley
Director, Maine Governor’s Office
of Health Policy and Finance
Jane Cline
Commissioner, West Virginia
Office of Insurance

WHAT IS THE OVERALL
VISION OF YOUR EXCHANGE?

One Exchange
• Administrative efficiencies
• Intersection of individuals / self-employed / small
business
– Will subsidy eligible & employed in small
business
join as individuals?
• Purchasing clout
Trish Riley
Draft recommendations to new
Governor & Legislature re: Exchange

Regional Exchanges
The ACA prescribes that an
Exchange may operate in more
than one State if—
(A) each State in which such
Exchange operates permits
such operation; and
(B) the Secretary approves
such regional or interstate
Exchange.
• Benefits
• Create larger risk pools
• Create larger markets
• Admin. economy of scale
• Portability across borders
• Barriers:
• Risk Pool dynamics
• State regulator autonomy
• State Mandated Benefits
• Governance
• Risk Adjustment
Jane Cline

Administrative Agreements
States do not have to share
risk pools or even borders to
work together on the health
insurance exchange
Adjacent and non adjacent
states may find great
savings, particularly on IT
infrastructure, by entering
into compacts to share
exchange administrative
functions
• Benefits
• Leverage down vendor
costs
• Share best practices
• Share maintenance cost
• Barriers:
• State autonomy
• Exchange strategy
coordination
• State procurement laws
Jane Cline

WHAT WILL THE
GOVERNANCE STRUCTURE BE?

Maine’s Exchange Governance Options
1. Non-Profit?
Pros
• Least influenced by political
environment
• Most nimble as it will not be
constrained by state
procurement agencies and HR
rules
• Potentially better able to
compete for highly skilled staff
• It’s not government so some
may trust it more
• Traditionally private functions
may be easier to carry out
Cons
• Hardest entity to ensure that
state priorities are being carried
out
• May be difficult to coordinate
across state and federal
agencies
• Difficult entity for sharing
confidential information
• Government still remains
responsible for carrying out ACA,
yet Governor and legislature
have least accountability here
Trish Riley

2. Existing Government Agency?
Pros
• Ensures state priorities and goals
are being met
• Easiest coordination with federal
and other state agencies
• Greatest opportunity to ensure
transparency and accountability to
state
• Confidential information more
easily shared across state
agencies
• Director appointed by
Commissioner or Governor
Cons
• Agency led by Commissioner that
serves at the pleasure of the Governor
• No diverse governing board to assist
with technical and policy issues
• Don’t want to create new agency and
Exchange functions may get lost or
downplayed in existing agency
• May carry stigma as governmental
agency
• Most influenced by political
environment
• Less nimble as it must follow state
procurement and HR laws
Trish Riley

3. Independent / Quasi- State Agency?
Pros
• Better site for state priorities
• Easier to coordinate with federal
and state agencies
• Better accountability and more
transparency
• Can appoint governing board composed
of people with technical expertise
• Board appointed by Governor and
Legislature
• Executive Director to serve at pleasure of
the Board
• Flexibility from some state procurement
and HR laws
• May be better able to interact with private
sector than government agency
Cons
• Sharing of confidential information may be
problematic
• May carry stigma with consumers
(individuals and businesses) as
governmental agency
• May be somewhat influenced by political
environment
• Less able to ensure accountability and
transparency to state government than full
governmental entity
• Executive and Legislative branches of
government have less control than over a
state agency; more than over a non-profit
Trish Riley

Exchange Governance
Options concerning
exchange governance:
• State Agency
• Nonprofit created by
State
• Federal
Regardless of governance,
state entities must be
engaged:
• Governor’s Office
• Insurance Regulator
• Medicaid
• CHIP
• Social Services
• Public Health
Jane Cline

WV Exchange Governance
Governance Proposal
Recommended that HIX exist
within the State’s insurance
regulator
Recommended that HIX have
board and that this board
have autonomy to make
policy decisions independent
of the regulator
Recommendation Rationale
• State Authority
• Accountability to citizens
• Administrative
streamlining
• Regulatory Continuity
• Board supported but
independent
• Effective model already
exists
Jane Cline

HOW WILL YOU COORDINATE
ELIGIBILITY AND
ENROLLMENT?

PROPOSALS FOR GOVERNOR-ELECT & NEW LEGISLATURE
Medicaid in an Exchange Environment
400% FPL
138% Medicaid / DHHS
Integrated Eligibility System
0%
Exchange “Front Door”
PROPOSALS FOR GOVERNOR-
ELECT & NEW LEGISLATURE
Trish Riley

Eligibility/Enrollment
• Re-Think Medicaid & Subsidies
• Single front-door for subsidies, 0% – 400% FPL
- MAGI
• Behind the scenes cascade into DHHS integrated delivery system
• No wrong door – Can access subsidies / exchange via DHHS as
well
• Build on current capacity
A. Medicaid Eligibility
• Integrated system with social services
• Needs some modernization to comply with ACA
• Needs to continue for Medicaid populations
B. Dirigo Health Agency
• Website & calculator
• Subsidy eligibility & determination
• Link to Medicaid
• (www.dirgohealth.maine.gov)
• Developed added Exchange capacities via SHAP grant
(Vouchers)
Trish Riley

Eligibility and Enrollment
HIX Eligibility Role
Exchange must inform
individuals of eligibility for
state’s Medicaid, CHIP, and
federal subsidies.
Exchanges must also
determine eligibility for
mandate exemption
HIX Enrollment Role
Exchange must establish a
way to apply for enrollment
in Medicaid, SCHIP
HHS will provide single
streamlined form that may
be used in applying for all
applicable state health
subsidy programs
Jane Cline

Options
• Use Federal IT/Early Innovator
• Have eligibility/enrollment for
public plans take place in
current system with HIX MOU
• Develop two
eligibility/enrollment doors
(one public plans, one HIX)
• HIX develop new IT system as
single entry point
• Hybrid of various options
Strategy
• Work with stakeholders
• Determine core functions
• Maximize federal resources
• Administratively and
operationally efficient
• Ensure seamless and simple
for consumers
• Do not compound confusion-
thoroughly test
Eligibility and Enrollment
Systems
Jane Cline

WHAT TOOLS CAN YOU
EMPLOY TO ACHIEVE
AFFORDABILITY?

• Impact of national plans?
• Robust marketplace
– Patient Centered Medical Homes
• Payment Reform Workgroup
• Demos
Affordability
Trish Riley

• Negotiate with plans for
exchange premiums
• Allow market competition
to drive plan premiums
• Through economy of
scale, perform insurance
administrative functions
more efficiently
• Leverage exchange pool
for lower provider
payments
• Place price of using
producer/ navigator on the
consumer
• Limit number of plans
available and drive down
premiums through auction
of plan slots
Mechanism for Cost Saving?
Jane Cline

Exchange Planning Grant TIMELINE
Jane Cline

HOW WILL YOU ENGAGE
STAKEHOLDERS?

Stakeholder Involvement
Governor
Governor’s Office of
Health Policy & Finance
Senior Level Health Reform
Implementation
Steering Committee
Subcommittees with Agency Staff
Legislature
Joint Select Committee on
Health Reform
Opportunities and Implementation
Advisory Council on
Health Systems Development
(Advises Legislature and Governor)
Funded in part by HRSA SHAP Grant
Trish Riley

Stakeholder Engagement
• Address producer concerns
• Engage consumers at every
level (individual, small
group, large group)
• Use focus groups to reach
underserved demographics
• Don’t forget providers
• Must get buy-in from
Governor
• Must communicate with
constituent state agencies
like CHIP, Medicaid
• Engage Legislature
• Engage carriers in
regulator/issuer meetings
Jane Cline

Stakeholder Strategy
• Will have HIX request for
comment running concurrent
to stakeholder meetings
• After stakeholder meetings
will develop community of
interest groups to focus on
specific exchange issues
• Will have focus groups to
ensure that consumer input
incorporated into plan
• Continuously engage
stakeholders on their own
turf (quarterly/ annual
meetings)
• Setting up website to allow
consumers to see process
behind HIX planning and
research
• Launching statewide
stakeholder meetings over
next two months
Jane Cline

Questions and Answers
Please submit your questions through the
chat function

www.nashp.org

www.SHAPaccess.org

State-developed resources:
• State-Specific Overview Analyses
• Health Reform Work Plans,
Timelines, and Progress Reports
• Coordinators and Coordinating
Bodies
• Fiscal Analyses
• Proposals for Federal Funding
• State Laws, Rules, and
Regulations
• State Implementation Websites
Share your implementation resources with us!
Send to statereforum@nashp.org
Check out Priority 1
for state exchange
resources! Over 50
state exchange
resources from 18
states now available.
www.statereforum.org

Please feel free to contact the SHAP team with any questions.
Thank You
Anne Gauthier
Senior Fellow
agauthier@nashp.org
Kathy Witgert
Program Manager
kwitgert@nashp.org
Christina Miller
Research Assistant
cmiller@nashp.org
Sonya Schwartz
Program Director
sschwartz@nashp.org
Chris Cantrell
Research Assistant
ccantrell@nashp.org

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