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maxenroll Bachrach 033011.pdf - National Academy for State Health ...

maxenroll Bachrach 033011.pdf - National Academy for State Health ...

This report is a product

This report is a product of Maximizing Enrollment: Transforming State Health Coverage, which is a $15million, four-year initiative of the Robert Wood Johnson Foundation (RWJF). Under the direction of theNational Academy for State Health Policy (NASHP), which serves as the national program office,Maximizing Enrollment aims to help states transform their eligibility and enrollment systems to improveenrollment and retention of children who are now eligible for Medicaid and the Children’s HealthInsurance Program (CHIP), and to prepare to enroll newly eligible individuals and families in public andpublicly subsidized health coverage. By helping selected states improve their systems, policies andprocedures — and measure the impact of these changes — RWJF hopes not only to increase the efficiencyand effectiveness of these programs in enrolling and retaining those eligible, but to share knowledge aboutwhat works to increase enrollment and retention within public and publicly subsidized health coverage inall states.About the National Academy for State Health PolicyThe National Academy for State Health Policy (NASHP) is an independent academy of state healthpolicymakers working together to identify emerging issues, develop policy solutions, and improve statehealth policy and practice.http://www.nashp.orgAbout Manatt Health SolutionsManatt Health Solutions (MHS) is an interdisciplinary policy and business advisory division of Manatt,Phelps & Phillips, LLP, one of the nation's premier law and consulting firms. MHS helps clients developand implement strategies to address their greatest challenges, improve performance and position themselvesfor long-term sustainability and growth. MHS is currently advising multiple foundations, stategovernments, health care providers and payers, and other health care stakeholder organizations onimplementation of federal health reformAcknowledgementsThe Authors want to acknowledge the input and assistance they received from a number ofpeople. First and foremost, the team at NASHP: Catherine Hess and Alice Weiss providedinvaluable guidance as we crafted this paper and Anne Gauthier’s editorial contributions madethe paper stronger. In addition, we want to thank John Bertko for helping us better understandand write the risk adjustment section of the paper. (Any mistakes, however, are entirely ourown.) Our colleagues at Manatt Health Solutions – Kinda Serafi, Alice Lam and Rachel Sam –helped with research and editing and were always available to help us think through a new idea.Last, but certainly not least, we want to thank the Robert Wood Johnson Foundation for fundingthis report.

TABLE OF CONTENTSExecutive Summary ............................................................................................................................. 1 Eligibility, Enrollment and Outreach ............................................................................................................................ 1 Health Plan Contracting, Standards and Requirements ....................................................................................... 1 Benefit Package Design ...................................................................................................................................................... 2 Exchange Infrastructure .................................................................................................................................................... 2 Introduction ........................................................................................................................................... 3 Eligibility, Enrollment and Outreach in the Exchange ............................................................. 5 Determining Eligibility for State Health Subsidy Programs ............................................................................... 5 Eligibility Issues Requiring Federal Resolution ................................................................................................. 6 Eligibility Issues Requiring State Resolution ...................................................................................................... 9 Enrolling Consumers in Coverage and Ensuring Coverage Continuity ...................................................... 11 Providing Consumer Outreach and Education ...................................................................................................... 12 Health Plan Contracting, Standards and Requirements in the Exchange ....................... 14 Health Plan Contracting .................................................................................................................................................. 14 Certification of Qualified Health Plans ..................................................................................................................... 15 Information and Reporting Requirements for QHPs .......................................................................................... 17 Risk Adjustment ................................................................................................................................................................. 18 Quality Strategies and Reporting ................................................................................................................................ 20 Benefit Package Design in the Exchange .................................................................................... 22 Essential Benefits ............................................................................................................................................................... 22 Medicaid “Benchmark” Benefits .................................................................................................................................. 22 Cost Sharing ......................................................................................................................................................................... 25 Exchange Infrastructure: Governance, Operations, and Finance ..................................... 27 Governing the Exchange ................................................................................................................................................. 27 Operating the Exchange: Systems and Administrative Resources ............................................................... 28 Financing the Exchange .................................................................................................................................................. 30 Conclusion ............................................................................................................................................ 35

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