Federally-facilitated Exchange Partnership Planning in Arkansas:

Where Weve Been; Where We Are Now; and Lessons Learned

Presented to

Idaho Health Insurance Exchange Working Group

October 9, 2012

Cynthia Crone, APN Arkansas Insurance Department

Arkansas Landscape
Low Per Capita Income Poor Health Status Indicators Large and Growing Percentage of Uninsured Medicaid Deficit Expected in 2013

Health Agency Leaders Working Together to Improve Health System

Arkansas Health System Improvements

Payment and Quality Transformation using EvidenceBased Episodes of Care PCMC Model Workforce Health Information Technology

Health Benefits Exchange

ACA and Arkansas Political Landscape

Popular Governor Democrats are Majority in Legislature, Growing Number of Republicans Vocal, Active TEA Party Republicans Opposed to ACA and therefore to Exchanges

Exchange Planning
Arkansas Insurance Department is Lead Agency

Commissioner is Governor Appointee and Planning Authority Funding to Date Exchange Planning Level One Cooperative Agreements (2)

How Many Will Be Affected?

An estimated 572,000 Arkansans will be eligible for Exchange coverage beginning January 1, 2014. It is conservatively estimated that:
328,000 more nonelderly Arkansans will enroll (resulting in a 60% decrease in uninsured post-ACA). There will be a $615 million reduction in uncompensated care among nonelderly (a 68% change post ACA). There will be $478 million in federal subsidies provided for Arkansans to purchase insurance.
Source: State Progress Toward Health Reform Implementation: Slower Moving States Have Much to Gain, Timely Analysis of Immediate Health Policy Issues, January 2012 Urban Institute analysis, HIPSM

As Is (Pre-ACA)
(ACHI, 2012)

2014 (Post ACA)

(ACHI, 2012)

Development of Partnership Model

Arkansas did not obtain authority for State Exchange - 2011 Arkansas did not seek Level One funding - September - 2011 Partnership Option Announced by CCIIO - September 2011 Exchange Planning Steering Committee recommended that planning for a State Exchange end - November 2011

Obtained Governors approval to explore Partnership Model and apply for Level One Funding - December, 2011

Arkansas is Planning Full Partnership Model

Plan Management

Consumer Assistance Medicaid FFE Integration

Level One Funding and Waiting

First Level One funding award received February 2012 Required to obtain Legislative Approval for Spending While waiting
Exchange Planning Grant No Cost Extension kept small staff operating Designed Stakeholder Engagement Process Designed Contractor/Staff Communication Process Implemented Advanced Procurement and Hiring Activities

Level One Appropriation obtained April 20, 2012

Stakeholder Inclusion Operational Model

Planning Staff & Advisory Committees Research / Alternatives Analysis

Advisory Committees Develop Recommendations with Alternatives

Steering Committee Final Recommendation to Commissioner

Steering Committee
The Steering Committee meets once monthly and includes representation of the following:
Insurance Department (2) Department of Human Services (2) Arkansas Health Agency Leaders Department of Finance & Administration Advisory Committee CoChairs (6) State Legislature (2) Governors Office Stakeholders At Large (3)

Topic Calendars
May June July August
IPA Application & Application Review

Sept

Oct
IPA Performance Metrics

IPA Eligibility

IPA Certification & Recertification

IPA Training Options

IPA Program Funding

Nov
IPA Ongoing Monitoring

May
Essential Health Benefits

June

July

August
Network Adequacy, Market Standard and Risk Pool Definition

Sept
QHP Elements Application Submission and Transmission of Data Elements

Oct
QHP Application & Certification Format and Content

Active Purchaser vs. Open Market

Active Purchaser vs. Open Market

Consumer Assistance In-Person Assisters (IPAs)

Categories - Navigators - Enrollment Assisters - Licensed agents and brokers (producers)

Arkansas Insurance Department will: - Certify, recertify, decertify individual IPAs - Oversee IPA training and performance - Contract with IPA entities to facilitate enrollment and postenrollment complaint resolution as needed

Consumer Assistance Outreach and Education

Outreach Education
Two Phases Planned for 2012-2013
Phase I General ACA/Exchange Education Phase II Move Eligible Residents toward Enrollment

IPA Specialists through Home Town Health

Complaint Resolution
FFE Eligibility/Enrollment AID Consumer Services Division

Current Outreach/Education - Phase I

Interagency Contracts UAMS
Opinion Poll to guide messaging for Phase I Focus Groups to assist with Naming/Branding Speakers Bureau Initial Message Development/Media Buys

U of A Partners for Inclusive Communities

County Meetings Quarterly Updates Stakeholder Summit

Staff/Consultants - IPA Outreach

In Person Assister (IPA) Entities

AID will contract with community-based IPA entities that will engage certified IPAs We estimate 535 IPAs needed for initial Open Enrollment decreasing to 134 until next Open Enrollment Continuous, real-time feedback from the FFE will be critical in continuously assessing our successes and initiating needed improvements.

Key Dates and Benchmarks In-Person Assisters

IPA IT vendor selection IPA Program and Processes Defined by December 2012 IPA RFP Complete by January 2013 IPA RFP Advertised by February 2013 IPA Awards by May 2013 IPA Training by June 2013 Certified IPAs in the Field July 2013 Open Enrollment October 2013

Plan Management Activities

Select EHB Benchmark Plan Define QHP Certification Criteria and Processes

Decrease financial start up risks for issuers - Risk Adjustment - Reinsurance (temporary) - Risk Corridor (temporary)

Plan Management Processes

Leverage Existing Processes within AID where they exist:
Life and Health Rate Review Consumer Services Finance License Legal

Use Enhanced SERFF System

EHB Benchmark Considerations

Compliance with ACA Consumer Protection Arkansas Health Needs Overall Premium Costs and Value State Mandated Benefits Wellness Benefits Other

EHB Benchmark Rule 103 Directive 2-2012

Arkansas Blue Cross Blue Shield Health Advantage (POS) with following Substitutions:
QualChoice Federal Plan Mental Health and Substance Abuse Treatment Services ARKids First (CHIP) Pediatric Dental Blue Cross Blue Shield Federal Plan (Blue Vision High) for Pediatric Vision

Habilitative Services will likely be determined by carriers with State oversight

Selected Arkansas QHP Certification Criteria

Meet ACA Standards for Benefits and Actuarial Value Increase Competition in Marketplace Arkansas Specifics:
Will use a certification approach for plan selection. Will not require network adequacy or quality standards that exceed federal ACA requirements in year one. The Steering Committee acknowledges the emerging importance of Arkansass Payment Improvement Initiative in advancing quality and affordability and the Exchange may engage or require carriers to adopt specific quality improvement strategies as a condition of having their QHPs certified to be marketed and sold on the Exchange.

Selected Arkansas QHP Certification Criteria

Will not require carriers to offer their QHPs statewide as a condition of Exchange certification in year one, but recommends consideration of a regional approach with the goal of statewide coverage.* Arkansas may limit the number of plans or benefit designs that may be offered by a carrier on the exchange.* Pass on options related to incentivizing carriers.

* Steering Committee recommended changes from PMAC recommendation.

Expected Rules
Network Adequacy QHP Certification In Person Assister Certification More

Medicaid-Exchange Integration

Continuous Coverage Across Insurance Affordability Programs

How to mitigate negative effects of churning or family members in different plans Plan to study options using data that evaluates costs and quality by benefit design, consumer demand, and provider capacity, to include:
Current FFS QHP Option Medicaid Plan Option Bridge Plan

Summary of Exchange Planning to Date

Planning Grant Background Research; Administrative Supplement to do Carrier Survey and more Quality Definitions Level One A Contractors and Staff to begin serious Plan Management and Consumer Assistance Planning Level One B Prepare for October 1, 2013 Open Enrollment and Full Implementation of Partnership Model by January 1, 2014; Study options to mitigate negative effects of IAP churning and promote continuity of coverage.

Key Milestones
Planning Review May, 2012
On Track; Big Take Away was that Partnership States would not issue Navigator Grants Long-term financial sustainability model for FFE-P unknown

Design Review October 1-2, 2012

CCIIO/CMS staff very helpful; Arkansas waived out of most Blueprint items for Partnership Model Federal officials willing to negotiate implementation issues with state; Long-term financial issues for FFE-P not completely resolved, but state must be paid for service

Blueprint Application and Declaration Letter November 16, 2012

Think about long- term plans Collaborate with other states

Key Milestones
QHP and Navigator Certification and Operational Processes Design Complete by end of 2012 DHHS Conditional Approval as Partnership FFE by January 1, 2013

Implementation Review Summer 2013

Open Enrollment October 1, 2013 and Partnership Exchange is Fully Operational Covering Consumers by January 1, 2014 The Future??

 Advance Planning for Hiring and Procurement Carefully Plan Stakeholder Engagement Model; Attract Diverse and Strong Leaders Integrate Contractors into Planning and Project Management Utilize CCIIO Staff and Other Resources Integrate with Other Health Improvement Initiatives Be Persistent in Relationship Building

Building Consensus
Keep on message: Arkansas will not have a State Exchange FFE Partnership provides Arkansas: Ability to meet ACA deadlines for compliance
with law
Opportunity to tailor Plan Management and Consumer Assistance components to meet needs of Arkansans Local design and implementation of Consumer Services and Protections Funding for connecting with FFE

 Partnership with Medicaid Agency is critical Consider and document majority and minority opinions

Make decisions Move on

Keep

consumer focus

Summary
Arkansas has a tremendous need for coverage expansion. Cost, quality, and access improvements in Arkansass healthcare system will benefit all Arkansans. The Partnership Exchange allows Arkansas Insurance Department to continue regulatory and consumer protection functions for our residents. Intentional efforts to mitigate negative effects of churning and promote continuous coverage will be especially important with our population. Transparency and inclusivity in planning is critical. Keep consumer focus a priority.

Questions/Comments

Cynthia.Crone@Arkansas.Gov 5016833634

www.hbe.arkansas.gov