On Thursday, January 3, CCIIO released new guidance on state partnership exchanges that provides further information on the role of a state and the role of the federal government in both a plan management and a consumer assistance partnership exchange. Topics covered in the guidance include:
Plan Management Partnership Exchanges
· The scope of state responsibilities, including recommending plans for qualified health plan (QHP) certification, recertification, and decertification to HHS.
· The scope of HHS responsibilities, including receiving, approving (as appropriate), implementing, and overseeing state QHP certification and recertification recommendations.
· Information regarding requirements for a state-specific memorandum of understanding (MOU) with HHS, which will include a description of how each state approved for a plan management partnership will review health plans for exchange certification.
· A recommended timeline for state plan management partnership activities, including a requirement that partner states complete their part of the QHP certification process and provide required plan data and certification recommendations to HHS by July 31, 2013.
Consumer Assistance Partnership Exchanges
· The scope of state responsibilities, including managing navigators, and developing, implementing and managing an in-person assistance (IPA) program.
· The scope of HHS responsibilities, including funding and awarding grants to navigator entities, establishing conflict of interest, cultural and linguistic competency, and training standards for navigators, providing training for navigators and in-person assisters, and operating a single State Partnership Exchange call center and website.
· State use of 1311 (exchange establishment) funding for navigator and in-person assistance programs and state options to permit agents and brokers to enroll consumers in qualified health plans through the exchange, develop additional training for navigators and in-person assisters, and conduct exchange outreach and education activities.
· Information on the development of outreach and education plans.States must submit an outline of plans for these activities to HHS by March 29, 2013.
Of particular interest to health centers is the chart in Appendix A of the Guidance entitled “HHS Approach for Certification of FFE QHPs for the 2014 Coverage Year.” One of the requirements covered in that chart is “Inclusion of ECPs” (page 21 of the Guidance) in which the column entitled “HHS Approach for Certification of QHPs” states:
“Based on HHS-developed ECP list, verify one of the following:
•Issuer achieves at least 20% ECP participation in network in the service area, agrees to offer contracts to at least one ECP of each type available by county, and agrees to offer contracts to all available Indian providers****;
•Issuer achieves at least 10% ECP participation in network in the service area, and submits a satisfactory narrative justification as part of its Issuer Application; or
•Issuer fails to achieve either standard but submits a satisfactory narrative justification as part of its Issuer Application.
Justifications submitted by issuers that fail to achieve either standard will undergo stricter review by CMS.
The above standard is a transitional policy to accommodate first year timeframes that “based on HHS-developed ECP list
****Contracts offered must reflect the generally applicable payment rates of the issuer, and must account for the payments to FQHCs under 1902(bb), unless the FQHC and issuer mutually agree on other rates. Contracts offered to Indian providers are encouraged include the QHP Addendum for Indian providers”
The ‘HHS-developed ECP list’ mentioned in the above-quoted column is not included in this chart—however, it is our understanding that FQHCs are specifically included on this list and that the list will be published by CCIIO in subsequent guidance.
For more information, contact Roger Schwartz at email@example.com; 202-296-0158.