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July Exchange Board Meeting: QHP Policies

The July 23 Exchange board meeting was held in Oakland, the second time the board convened outside of Sacramento.  The focus was on Qualified Health Plan (QHP) policies and service center options.

During the Executive Director’s report, Peter Lee summarized progress on the Federal Level 1.2 Establishment grant, the CalHEERS project, and legislative updates.  Accenture, who was awarded the CalHEERS IT contract, presented on the overview and implementation timelines.  The CalHEERS system will include the following functionality:

  • first class user portal
  • shop and compare tools
  • assister registration
  • SHOP employer registration and setup
  • online help
  • eligibility and enrollment
  • plan and benefits assistance
  • financial and plan management
  • reporting
  • education and outreach reports

The following show implementation timelines, with early portal functionality going live during the second half of next year.

 

Qualified Health Plan Policies

Exchange and PricewaterhouseCoopers (PwC) staff presented QHP options and preliminary recommendations, which are italicized.

Metal level tiers for QHP bids:

  • Option A: require all metal tiers per QHP bid (plan issuers must propose a QHP product for all metal tiers and catastrophic in each geographic region in which it bids)
  • Option B: require select metal tiers per QHP plan bid (full metal tier and catastrophic requirement may be met by proposing other metal tier QHPs in at least one other geography

Number of QHP product bids per issuer

  • Option A: allow one QHP bid per issuer (limited to one per geographic area)
  • Option B: limited number of QHP bids per issuer (2-3 bids per geographic region)
  • Option C: allow any number of QHP bids

Geographic coverage by health plans

  • Option A: require health plan bid in all licensed areas
  • Option B: allow health plan bid in subset of licensed areas (permit bids for subset of geographic regions in which issuer is licensed, but have at least one product that fully covers entire region for which issuer is licensed)
  • Option C: health plan must cover defined service area (permit bids for only services areas where issuer can demonstrate coverage of entire geographic area)

Standardization of family structure rating factors

  • Option A: do not standardize
  • Option B: standardize family tier structure, but allow issuers to determine tier ratios
  • Option C: standardize family tier structure and tier ratios

Standardization of age factors

  • Option A: do not standardize
  • Option B: standardize age factors

Requirement that issuers cover entire geographic regions

  • Option A: do not require issuers to cover entire region
  • Option B: require issuers to cover entire region
  • Option C: require issuers to cover entire region for which they are licensed

Allowable rate adjustment for tobacco use

  • Option A: prohibit application of tobacco use rating factors
  • Option B: allow application of full magnitude of tobacco use by ACA (1.5 factor)
  • Option C: conduct further research on pros and cons of requiring a limited (e.g. 5%) rate-up for tobacco use

Wellness program incentives (with clear limits; measure impact on enrollment and care)

  • Option A: prohibit wellness program incentives
  • Option B: allow wellness program incentives

Standardization of cost sharing provisions

  • Option A: no standardization of cost-sharing components of benefit plans offered in the Exchange
  • Option B: standardization of major cost-sharing components of benefit plans and allow limited customization
  • Option C: strict standardization of all possible cost-sharing components of benefit plans

Standardization of benefit exclusions and limits

  • Option A: no standardization of benefit limits and exclusions in benefit plans offered in the Exchange
  • Option B: standardize major benefit limits and exclusions and allow limited customization
  • Option C: strict standardization of all possible benefit limits and exclusions

Standardization of drug formularies

  • Option A: require formularies to meet at least the ACA minimum standard of at least one drug per class/category
  • Option B: require formularies to meet at least Medicare Part D minimum standard of at least 2 drugs per class/category

Value-based benefit designs in the context of benefit standardization

  • Option A: prohibit value-based benefit designs
  • Option B: allow value-based benefit designs that lower patient out-of-pocket costs or provide financial rewards

Standardization of minimum out-of-network benefits

  • Option A: do not standardize minimum out-of-network benefits
  • Option B: standardize minimum out-of-network benefits

Plan choices for individuals with income between 100-250% of FPL

  • Option A: allow choice only among any silver plan available to that individual/family
  • Option B: allow choice only among bronze and silver plans available to that individual/family. The rationale for limiting choice to this income band is because silver plans are the only tier that has cost-sharing reductions as well as premium subsidies; cost-sharing reductions do not apply to any other tier of plans, nor do they apply to individuals/families with greater income
  • Option C: allow choice of plans from any tier

Plan choices for individuals with income between 250-400% of FPL

  • Option A: allow choice only among any silver plan available to that individual/family
  • Option B: allow choice only among bronze and silver plans available to that individual/family
  • Option C: allow choice of plans from any tier

Consideration of exchange provider network access adequacy standards for QHP certification

  • Option A: adopt regulatory requirements of QHP bidder’s current regulatory agency (CDI and DMHC for respective PPOs and HMOs)
  • Option B: adopt regulatory requirements of DMHC for all QHP bidders
  • Option C: adopt additional exchange specific standards for all QHP certification above and beyond the regulators respective provider network adequacy standards

Provider network access: adequacy standards

  • Option A: regulator (DMHC/CDI) certifies a QHP bidder’s network complies with applicable network access standard
  • Option B: exchange requires regular additional provider network surveys or analysis for all QHP to benchmark or to monitor potential areas of concern
  • Option C: exchange requires increased frequency and detail in geo-access reporting

Definition of Essential Community Providers

  • Option A: define ECP as the minimum standard limited to the list of 340B and 1927 providers
  • Option B: incorporate minimum standard above and broadens the list of ECP to include physicians, clinics and hospitals which have demonstrated service to the Medi-Cal, low-income and medically underserved population

Definition of “sufficient” participation of ECPs

  • Option A: QHP may use existing regulatory network access criteria to demonstrate ECP network adequacy based on low-income target population
  • Option B: demonstrate minimum proportion of network overlap among QHP and Medi-Cal managed care, Healthy Families program networks and/or independent physician providers serving a high volume of Medi-Cal patients in their practices

Payment rates to FQHCs

  • Option A: require QHPs to contract with all FQHCs and mandate payment under terms of §1902(b) of the Act or the PPS rate
  • Option B: encourage inclusion of FQHCs in QHP provider networks and require payment under terms of §1902(b) of the Act at the PPS rate
  • Option C: encourage inclusion of FQHCs in QHP networks and require payment at fair compensation by the QHP defined as rates no less than the generally applicable rates of the issuer

Accreditation standards and reporting

  • Option A: require NCQA health plan accreditation as a minimum requirement for inclusion as a QHP in the exchange
  • Option B: require reporting of CAHPS and HEDIS measures consistent with Medi-Cal managed care specifications and an interim NCQA health plan accreditation by 2014; commendable NCQA accreditation required by 2015
  • Option C: require at least commendable NCQA health plan accreditation and NCQA physician hospital quality certification by 2015

Use of a Health Risk Assessment Tool or other plan-based wellness promotion initiatives

  • Option A: require completion of health risk assessment as a part of the enrollment process
  • Option B: require completion of a health plan health risk assessment as part of the enrollment process
  • Option C: health plans provide an optional health risk assessment tool

Provision of a wellness program by the Exchange

  • Option A: exchange selects an additional vendor to augment issuer-based programs
  • Option B: exchange promotes use of wellness programs offered by issuers
  • Option C: exchange establishes requirements for the wellness programs that are offered by issuers

Use of financial incentives by plans to promote wellness

  • Option A: allow health plan issuers to use incentives as an optional program
  • Option B: require health plan issuers to use a common set of incentives
  • Option C: prohibit health plan issuers from using incentives

Role of exchange in community and public health issues

  • Option A: engage in public and community health efforts in conjunction with its outreach and marketing campaign
  • Option B: exchange encourages health plans to address public health issues
  • Option C: exchange does not engage in public and community health issues

Offering supplemental benefits in the individual and SHOP exchanges

  • Option A: offer supplemental benefits in both exchanges
  • Option B: offer supplemental benefits only in the SHOP exchange
  • Option C: don’t offer supplemental benefits

Structuring individual supplemental benefit offerings

  • Option A: offer dental and vision coverage only embedded as part of medical QHPs
  • Option B: offer stand-alone dental plans and medical plans
  • Option C: offer a combination of (a) stand-alone dental, vision and medical plans; and (b) medical plans with embedded dental and vision benefits

A reactor panel followed, which consisted of Richard Scheffler, professor at the Goldman School of Public Policy at UC-Berkeley; Anthony Wright, Executive Director of Health Access; Charles Bacchi, Executive Vice President of the California Association of Health Plans; Anne McLeod, Senior Vice President of Health Policy at the California Hospital Association; Dr. Larry deGhetaldi, CEO of Sutter Health – Santa Cruz; and Catherine Dodd, Director of the San Francisco Health Service System.

The board is soliciting comments on these recommendations, and are due by August 6.

 

Service Center Options

Exchange staff revised service center options presented during the previous exchange board meeting, into two options:

  • Centralized multi-site service center model
  • Integrated state/consortia service center model

The former is a combination of the first 3 options presented during the June 19 board meeting, while the latter is similar to the fourth county-based option.

Centralized multi-site service center model

Advantages

  • Centralized management and technology infrastructure
  • Multi-marketing hiring pool and quality of resources from accessing selected labor markets
  • Establish consistent work rules, staffing models and hours of operations to meet the demands of health reform
  • Flexibility to increase and decrease staffing across multiple locations to meet volume fluctuations and disaster response
  • Centralized support and trained staff to provide assistance for Assisters and Navigators
  • Standardized training and quality programs administered in a few large locations
  • Ability to drive high utilization with large, skill-based service teams
  • Standard performance management program administered across a small number of locations

Disadvantages

  • Implementation complexities based on multiple locations
  • Initial development of building and launching new physical locations
  • Initial investment to launch centralized technology infrastructure
  • Significant effort to hire and train new staff in short timeframe
  • Potential customer experience variability due to multiple physical site locations

Integrated State/Consortia Model

Advantages

  • Builds on current infrastructure, staffing and management expertise
  • Multi-market hiring pool and quality of resources from multiple California labor markets
  • Experienced County eligibility staff and customer service staff to provide a core base
  • Flexibility to increase and decrease staffing across multiple locations to meet volume fluctuations and disaster response
  • Standardized training and quality programs administered in an undetermined number of locations
  • Horizontal program integration for both intake and ongoing eligibility determination
  • Scalable technology in place to support increased volumes

Disadvantages

  • Competing service demands from an array of County programs
  • Implementation complexity and costs to integrate multiple existing and new service center technologies
  • Potential customer experience and service delivery variability due to different technologies, management and operational approaches across multiple consortia physical site locations
  • Significant effort to hire and train new staff in short timeframe
  • Managing different hours of operations and work rules in the same facility with County programs

During the August 23 meeting, staff will provide recommendations to the board.

All meeting materials are available online.

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