Home » Blog » August Exchange Board Meeting: Individual Market, SHOP, QHP and Service Center Options

August Exchange Board Meeting: Individual Market, SHOP, QHP and Service Center Options

August’s Exchange board meeting was packed to the proverbial gills, with several important topics on the agenda: premium aggregation, individual exchange agent payment options, SHOP recommendations, QHP policies, and service center options.

During his Executive Director’s report, Peter Lee announced that the federal government had funded the Exchange’s Level 1.2 Grant for $196 million, the bulk of which will be put toward CalHEERS, the Exchange’s IT system.  David Panush provided a legislative update, and Diana Dooley was re-elected as chair for a second year-long term.  Chris Kelly, Senior Advisor for Marketing and Outreach, presented an overview on the branding/naming process, and highlighted some names under consideration:

  • Traditional names: CaliHealth, CalAccess, Welquest/Wellquest, Covered, CA/Covered, PACcess
  • Interesting names: Ursa, Healthifornia, Eureka, Avocado, BEneficia/Benefica, Cal-Vida, Condor

The naming is expected to be completed by September 28, with the overall branding project to be completed by November 1, 2012.

Individual Exchange: Premium Aggregation

Chief Operations Officer David Maxwell-Jolly reviewed individual market premium aggregation options which were presented during the May board meeting:

  • Exchange manages collection and aggregation of payments to plans
  • Exchange contracts with vendor to manage collection and aggregation
  • Subscribers pay plans directly

The approach recommended by staff was the third one (direct payment by enrollees to plans), because it will be less costly, simpler to administer, avoids predictable losses related to dishonored payments, and avoids potential confusion of Exchange enrollees regarding where payments are to be made for their coverage.  Despite some vocal opposition during public comments, the board voted to adopt the recommendations as presented.

Individual Exchange: Agent Payment Options

Michael Lujan and Sandra Hunt presented on options for potential agent payment in the individual exchange:

  • Option 1: plans pay agents directly
  • Option 2: Exchange pays agents
  • Option 3: Exchange pays agents as Navigators

Exchange staff recommended option 1, with some final policy issue recommendations:

  • Agents to assist Medi-Cal eligible individuals in completing their application, providing same full scope of counsel as would a Navigator, but not receive compensation for this service
  • No additional payments to General Agents for individual enrollees
  • Web-based agents compensated in the same manner as other agents
  • Assurance that consumers will have access to unbiased information and vesting of agent commissions

While the board has voted to adopt these recommendations, the Exchange is soliciting feedback on this topic.

Small Business Health Options Program 

Exchange staff summarized stakeholder feedback, and presented on changes to SHOP recommendations. Also, while Exchange staff recommends Option A and B, the board is soliciting feedback on options to optimize employer and health plan participation:

  • Option A: employer choice of tier, employee choice of plan
  • Option B: paired/defined choice with limited tier (employer chooses two issuers in a paired choice offering)
  • Option C: employer choice of plan, employee choice of tier
  • Option D: full employer choice
  • Option E: full paired choice
  • Option F: full employee choice

Qualified Health Plan Policies

Exchange staff also presented on revised recommendations to QHP policies and strategies.  Some revised recommendations include:

  • Adopt specific multi-year contract criteria: effective January 1, 2014, QHP issuers encouraged to enter into 3-year agreement
  • Standardize family tier structure but allow issuers to determine tier ratios (previous recommendation was to standardize both tiers and ratios)
  • Do not standardize age factors
  • Prohibit application of tobacco use rating factors (previous recommendation was to conduct further research on pros and cons of requiring a limited rate-up for tobacco use)
  • Require formularies to meet at least the ACA minimum standard of at least one drug per class/category (previous recommendation was to meet at least Medicare Part D minimum standard of at least 2 drugs per class/category)
  • Allow full choice of any tier with clear notice of risks for individuals with incomes between 100-250% of FPL (previous recommendation was to limit to bronze and silver plans)
  • Refine Essential Community Provider definition to include 340B and 1927 providers, DSH facilities and affiliated clinics, tribal and urban Indian health programs, clinics/health centers not listed as 340B, and providers serving low-income individuals as identified by participation in the Medi-Cal EHR Incentive Program

A summary of changes can be found online.  The board voted to adopt these recommendations, with Dr. Bob Ross noting that the Department of Managed Health Care (DMHC) should regulate all QHPs, instead of deferring to the current regulation oversight which is split across CDI and DMHC.

Service Center Options and Recommendations

The last item on the agenda was service center options. with Exchange staff presenting on revised options and recommendations.

Centralized Multi-Site Service Center Model

This model would have a centralized management/technology infrastructure at the state level, with 2-3 state locations that would provide support to those eligible for Exchange plans, while routing all Medi-Cal eligibility determinations, including those newly eligible and only subjected to a simple income test, to counties.  This model would use CalHEERS for enrollment.

Integrated State/Consortia Model

This model, proposed by the County Welfare Directors Association, would build upon current county infrastructure to to determine eligibility for Exchange plans, as well as potential Medi-Cal beneficiaries.  This model would have one state location, 31 county locations, and no dedicated queue.  This model would utilize the SAWS system, which is currently in use.



State/County Partnership Model

This model has one state location, up to 9 county locations, a dedicated queue to support general inquiries.  This option would use CalHEERS at the state level and a combination of SAWS and CalHEERS at the county level.

Staff made recommendations in support of the centralized multi-site service center model.  Kim Belshe questioned the reasoning behind not utilizing CalHEERS to its full potential by using it to enroll those newly eligible for Medi-Cal.  The board voted to adopt the staff’s recommendations; while four board members voted to adopt them, Belshe abstained.

All board materials are available online.  The next meeting will be held on September 18, where health plan solitication, consumer assistance/ombudsman options, outreach and education grant criteria, Exchange blueprint, and the Level 1.3 grant will be discussed.  Potential action may be taken on the organizational structure of SHOP, stakeholder consultation plans, and Exchange name and branding.

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