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Understanding State Efforts to Implement Exchanges   Avalere Health  2011 Audio Conference Series July 28, 2011 Enrique Ma...
Maryland Health Benefit Exchange Act of 2011 <ul><li>Signed into law April 12, 2011. </li></ul><ul><li>Established as inde...
Exchange Board Structure <ul><li>Three ex-officio (voting):  Secretary of Health, Insurance Commissioner and Executive Dir...
Conflicts of Interest <ul><li>A Board member may not have an affiliation with the following while serving as a member: </l...
Board Activities to Date <ul><li>Administrative Activities </li></ul><ul><ul><li>Bylaws </li></ul></ul><ul><ul><li>Vice Ch...
Exchange Personnel <ul><li>Phase 1 Recruitment </li></ul><ul><ul><li>Executive Director </li></ul></ul><ul><ul><ul><li>Ass...
Legislative Studies <ul><li>Operating Model:  Study the feasibility and desirability of the Exchange engaging in: selectiv...
Legislative Studies <ul><li>SHOP Exchange:  Study the design and function of the SHOP Exchange beyond the requirements of ...
Advisory Process Committees <ul><li>Operating Model and Insurance Rules </li></ul><ul><ul><li>Operating Model </li></ul></...
Level One Establishment Grant Administration and Operations Policy Development & Detailed Planning Information Technology ...
THANK YOU! <ul><li>Contact Information: </li></ul><ul><li>[email_address] </li></ul><ul><li>202-292-6729 </li></ul><ul><li...
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Understanding State Efforts to Implement Exchanges

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A presentation given by Enrique Martinez-Vidal on July 28 as part of the Avalere Health 2011 Audio Conference Series.

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Understanding State Efforts to Implement Exchanges

  1. 1. Understanding State Efforts to Implement Exchanges Avalere Health 2011 Audio Conference Series July 28, 2011 Enrique Martinez-Vidal Maryland Exchange Board Member Vice President, AcademyHealth Director, State Coverage Initiatives
  2. 2. Maryland Health Benefit Exchange Act of 2011 <ul><li>Signed into law April 12, 2011. </li></ul><ul><li>Established as independent unit of State government. </li></ul><ul><li>Specific provisions promote transparency, accountability, and flexibility. </li></ul><ul><li>Establishes core functions and duties required under the Affordable Care Act. </li></ul><ul><li>Identifies key policy issues to be studied and reported to Legislature in December. </li></ul>
  3. 3. Exchange Board Structure <ul><li>Three ex-officio (voting): Secretary of Health, Insurance Commissioner and Executive Director of the Maryland Health Care Commission </li></ul><ul><li>Three members representing employer and individual consumer interests (Governor appointed) </li></ul><ul><li>Three members with specific knowledge and expertise (Governor appointed) </li></ul><ul><ul><li>Individual health care coverage </li></ul></ul><ul><ul><li>Small employer-sponsored health care coverage </li></ul></ul><ul><ul><li>Health plan administration </li></ul></ul><ul><ul><li>Health care finance </li></ul></ul><ul><ul><li>Administration of public or private health care delivery systems </li></ul></ul><ul><li>Governor appoints Chair: Secretary of Health </li></ul>
  4. 4. Conflicts of Interest <ul><li>A Board member may not have an affiliation with the following while serving as a member: </li></ul><ul><ul><li>Carrier </li></ul></ul><ul><ul><li>Insurance producer </li></ul></ul><ul><ul><li>Third-party administrator </li></ul></ul><ul><ul><li>Managed care organization </li></ul></ul><ul><ul><li>Any other person contracting directly with the Exchange </li></ul></ul><ul><ul><li>Trade associations of any of the aforementioned entities </li></ul></ul><ul><ul><li>Any other association of entities in a position to contract directly with the Exchange </li></ul></ul>
  5. 5. Board Activities to Date <ul><li>Administrative Activities </li></ul><ul><ul><li>Bylaws </li></ul></ul><ul><ul><li>Vice Chair & Standing/Temporary Committee Appointments </li></ul></ul><ul><ul><li>Procurement Policies and Procedures </li></ul></ul><ul><ul><li>Scopes of Assistance for Procuring Legislative Studies (expedited procurement) </li></ul></ul><ul><ul><li>Advisory Process Committee Recommendations </li></ul></ul><ul><li>Establishment Grant Proposal </li></ul><ul><li>Advisory Process Committees </li></ul>
  6. 6. Exchange Personnel <ul><li>Phase 1 Recruitment </li></ul><ul><ul><li>Executive Director </li></ul></ul><ul><ul><ul><li>Assistant Attorney General </li></ul></ul></ul><ul><ul><li>Director of Policy </li></ul></ul><ul><ul><li>Director of Information Systems </li></ul></ul><ul><li>Phase 2 Recruitment </li></ul><ul><ul><li>Director of Operations </li></ul></ul><ul><ul><li>Director of Communications and Outreach </li></ul></ul><ul><ul><li>Executive Assistant </li></ul></ul>
  7. 7. Legislative Studies <ul><li>Operating Model: Study the feasibility and desirability of the Exchange engaging in: selective contracting, either through competitive bidding or a negotiation process similar to that used by large employers, to reduce health care costs and improve quality of care by certifying only those health benefit plans that meet certain requirements. </li></ul><ul><li>Insurance Market Rules (In/Out of Exchange) : Study the rules under which health benefit plans should be offered inside and outside the Exchange in order to mitigate adverse selection and encourage enrollment in the Exchange. </li></ul><ul><li>Navigators and Consumer Assistance : Study the design and operation of the Exchange’s Navigator Program and any other appropriate consumer assistance mechanisms. </li></ul>
  8. 8. Legislative Studies <ul><li>SHOP Exchange: Study the design and function of the SHOP Exchange beyond the requirements of the ACA, to promote quality, affordability, and portability. </li></ul><ul><li>Financial Model: Study how the Exchange can be self–sustaining by 2015 in compliance with the ACA. </li></ul><ul><li>Communications/Marketing: Study how the Exchange should conduct its public relations & advertising campaign, including what type of solicitation, if any, of individual consumers or employers, would be desirable and appropriate. </li></ul><ul><li>Conversion to Nonprofit (Due December 1, 2015): Study whether the Exchange should remain an independent public body or should become a nongovernmental, nonprofit entity. </li></ul>
  9. 9. Advisory Process Committees <ul><li>Operating Model and Insurance Rules </li></ul><ul><ul><li>Operating Model </li></ul></ul><ul><ul><li>Insurance Market Rules </li></ul></ul><ul><li>Navigator and Enrollment </li></ul><ul><ul><li>Navigators & Consumer Assistance </li></ul></ul><ul><ul><li>Communications & Marketing </li></ul></ul><ul><li>Small Business Exchange </li></ul><ul><ul><li>SHOP Exchange Study </li></ul></ul><ul><li>Financial Sustainability (later start date) </li></ul><ul><ul><li>Financial Sustainability </li></ul></ul>
  10. 10. Level One Establishment Grant Administration and Operations Policy Development & Detailed Planning Information Technology Foundation <ul><li>Exchange Staff </li></ul><ul><li>Supports Seven Positions (Initial Org Chart), Office space and administrative support </li></ul><ul><li>Consumer Assistance Program (CAP) </li></ul><ul><li>Strengthens OAG’s CAP program by maintaining core personnel and supporting IT investments </li></ul>Analytic support for legislative policy studies and detailed planning related to federal milestones <ul><li>Program Management, Requirement Management, Vendor Management/Analysis and most importantly Implementation Support for Technology Platform, System Integrator, IV&V and Requirement Tool Partner to ensure all of the following ACA Functions are implemented and tested to conform with federal mandates put forth by CMS and HHS: </li></ul><ul><li>Call Center, </li></ul><ul><li>Exchange Website and Calculator, </li></ul><ul><li>Premium Tax Credit and Cost-Sharing Reduction Calculator, </li></ul><ul><li>Navigator Program Eligibility determinations for Exchange participation, advance payment of premium tax credits, cost-sharing reductions, and Medicaid. </li></ul><ul><li>Seamless eligibility and enrollment process with Medicaid and applicable State health subsidy programs </li></ul><ul><li>Enrollment Process </li></ul><ul><li>Applications and Notices </li></ul><ul><li>Individual responsibility determination </li></ul><ul><li>Administration of premium tax credits and cost sharing reductions </li></ul><ul><li>Adjudication of appeals of eligibility determinations </li></ul><ul><li>Notifications and Appeals of Employer Liability </li></ul><ul><li>Information reporting to IRS and enrollees </li></ul><ul><li>Outreach and Education </li></ul><ul><li>Free Choice Vouchers </li></ul><ul><li>Risk adjustment and Transitional Reinsurance </li></ul><ul><li>SHOP Exchange-specific functions </li></ul>
  11. 11. THANK YOU! <ul><li>Contact Information: </li></ul><ul><li>[email_address] </li></ul><ul><li>202-292-6729 </li></ul><ul><li>www.statecoverage.org </li></ul><ul><li>www.statecoverage.org /health-reform-resources </li></ul>

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