Issue 7
November 2012
Table of Contents
- Community Partners Sought for Medicaid Outreach
- HBX Executive Board Update
- Comments Invited on Qualified Health Plan Application
- Recommendations Proposed for Navigator Program
- Essential Health Benefit Benchmark Submitted to HHS
- Public Meeting Calendar
www.healthreform.dc.gov
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The Affordable Care Act (ACA) changes Medicaid in several significant ways. First, the ACA expands Medicaid eligibility to childless adults under 133% of the Federal Poverty Line (FPL). Second, under the ACA, Medicaid eligibility for most groups will be based on modified adjusted gross income (MAGI), as defined in the tax code. Third, household composition for MAGI-based Medicaid groups will be largely based on the tax household, rather than who lives together. Fourth, the eligibility and recertification processes will be automated as much as possible, using electronic data sources to verify eligibility factors.
In order to ensure that Medicaid beneficiaries are well-informed of these changes, several District agencies will collaborate with community partners to conduct targeted outreach. We will use a “train the trainer” model, in which community partners commit to learn and be trained about Medicaid changes and then hold training sessions for their constituents. District agency partners will provide technical assistance and training materials.
Individuals and organizations that work with low-income populations and can commit to conducting outreach over the next six months about Medicaid changes are being recruited. If you are interested in participating, please email Miriam Straus and Lucy Wilson-Kear with your contact information and a sentence about the population you can reach.
The Health Benefit Exchange Executive Board met on October 3 and October 24. Click here for agendas and minutes of past Board meetings.
The next public meeting of the Health Benefit Exchange Authority Executive Board will be November 14 at 5:30 PM. The meeting will be held at 899 N. Capitol Street NE in Room 407.
The Affordable Care Act specifies that only “qualified health plans” (QHPs) may offer coverage through the Health Benefit Exchange (HBX) and specifies some requirements for plans to be “certified” as a QHP. The Department of Insurance, Securities and Banking (DISB) has issued a bulletin to inform and solicit comments on the requirements for certifying QHPs. Comments are due by close of business Tuesday, November 13, 2012.
Input is sought from carriers and other stakeholders to help design the application, which will be released in early 2013. Comments are invited on any area of the application, including data elements, submission evidence, overall design, and outstanding requirements. Other thoughts on QHP requirements that improve plan certification are also welcomed.
For additional information, contact Brendan Rose or Andre Beard at the Department of Insurance, Securities, and Banking (DISB).
The ACA requires each health benefit exchange to establish a Navigator Program to help individuals and businesses understand and enroll in available health care options. The Health Reform Implementation Committee's Operations Subcommittee developed Navigator Program Recommendations, which were presented to the Health Benefit Exchange Authority Executive Board at its October 24 meeting.
The recommendations are based on a report from The Crider Group on Navigator Program options and stakeholder feedback received on the report. Highlights of the Navigator Program recommendations include:
Navigator Roles
Navigators should provide only the five core assistance functions required by the ACA, which includes all necessary service for consumers in the District’s Exchange. Complying with the requirements in the ACA ensures that Navigators play an integral role in the “no wrong door” model for all Exchange users. It also ensures that Navigators will be able to assist with eligibility and enrollment functions related to health programs in the Exchange and refer consumers and small businesses for additional assistance as appropriate.
Producer Role
Producers (agents and brokers) should have the ability to serve small business and individuals in the District’s Exchange consistent with current practices. Details related to Producer compensation and appointment in the Exchange will be considered later with additional input from stakeholders.
Navigator Compensation Structure
Navigators should be compensated by a block grant that covers the provision of all required functions. Paying Navigators using a block grant structure versus payment per enrollee ensures that Navigator entities are paid adequately based on the wide range of responsibilities required under the ACA.
Navigator Certification
All Navigators should be certified for participation in the Exchange with certification requirements being met by completing required navigator training. Training would be designed to ensure that Navigators are competent in the needs of underserved and vulnerable populations, eligibility and enrollment procedures, the range of public programs, QHP options as well as proper handling of tax data and personal information.
The Health Benefit Exchange Authority Executive Board will vote on the proposed Navigator Program structure at an upcoming meeting. The Exchange will also procure a vendor to assist with the design and implementation of the Navigator Program.
The District submitted its Essential Health Benefits (EHB) Benchmark Plan to the US Department of Health and Human Services (HHS) on October 26, 2012. The Benchmark Plan is BlueCross BlueShield CareFirst Blue Preferred PPO Option 1, the largest small group plan currently available in the District. The pediatric dental and pediatric vision benefits were supplemented by the FEDVIP Blue Vision plan and FEDVIP MefLife plan.
Stakeholders reviewed the proposed benchmark and helped identify several benefit issues which require clarification. These concerns have been communicated to HHS and are explained in an October 29 Update to Stakeholders. These benefit issues are briefly summarized below:
Parity
There are discrepancies within the benchmark with respect to mental health and substance abuse parity. The District’s EHB submission did not set benefit limits on mental health and substance abuse services to allow flexibility once further guidance is received. There are also questions about parity between rehabilitative care and habilitative care. District law currently only defines habilitative care for children, while the ACA requires habilitative care for adults. Additional federal guidance is needed to address parity for these benefits.
Drug Formulary
The District’s benchmark plan includes a drug formulary; however, the final federal guidance on drug coverage has not been released. The District seeks to work with federal rule makers to establish a comprehensive drug coverage floor that meets the health care needs of diverse segments of the District’s population.
Pediatric Dental
Due to significant discrepancies in estimated pediatric dental costs, the District has reserved the right to adjust the currently proposed pediatric dental benefits. Further work with dental carriers, stakeholders, and federal agencies will be undertaken to ensure the pediatric dental benefit meets ACA requirements and intent, yet is affordable.
The District will continue to work with HHS to resolve these issues regarding the Essential Health Benefits.
Check out the General Frequently Asked Questions and Small Business Owners and Producers Frequently Asked Questions on the health reform website. If you don’t see your question, send it to healthreform@dc.gov. We will try to address it in future newsletters.
Thursday, November 8, 10:00 AM
HRIC Medicaid Expansion and Eligibility Subcommittee Meeting
Department of Human Services, 64 New York Avenue NE, 5th Floor Conference Room
Thursday, November 8, 2:00 PM
HRIC Health Delivery System Subcommittee Meeting
Department of Health, 899 North Capitol Street NE, Room 535
Wednesday, November 14, 5:30 PM
Health Benefit Exchange (HBX) Executive Board Public Meeting
Department of Health, 899 North Capitol Street NE, Room 407
Thursday, November 15, 2:30 PM
HRIC Exchange Operations Subcommittee Meeting
Department of Health Care Finance, 899 North Capitol Street NE, Room 6130
Wednesday, November 21, 2 PM
HRIC Communications Subcommittee Meeting
John A. Wilson Building, 1350 Pennsylvania Avenue NW, Room 306
Monday, November 26, 3:00 PM
HRIC Insurance Subcommittee Plan HBX Market Working Group Meeting
Department of Insurance, Securities and Banking, 810 First Street NE, 7th Floor
Wednesday, November 28, 5:30 PM
Health Benefit Exchange (HBX) Executive Board Public Meeting
Department of Health, 899 North Capitol Street NE, Room 407
Wednesday, December 5, 5:30 PM
HRIC Communications Subcommittee Meeting
John A. Wilson Building, 1350 Pennsylvania Avenue NW, Room 306
Produced by The Crider Group
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