New York Health Benefit Exchange Overview of Business Operations Blueprint: Overview of Business Operations Blueprint: Recommendations to the State Stakeholder Presentation February 16, 2012
Agenda Agenda • Purpose of Business Operations Blueprint Purpose of Business Operations Blueprint • Review of Exchange Principles relative to Operational Functions Operational Functions • Discussion of Core Work Processes 2
Purpose of Business Ops Blueprint Purpose of Business Ops Blueprint Provide New York State with a high level Provide New York State with a high level overview of the business functions that must be established the type of work that must be be established, the type of work that must be undertaken by exchange staff, and a relative timeline and chronological order for standing timeline and chronological order for standing up its Health Benefit Exchange 3
Purpose of Business Ops Blueprint (con’t) Purpose of Business Ops Blueprint (con t) • Other uses of document: – A starting point for the development of more detailed project plans for each core work process, – Identification of potential resource “bottlenecks” that may require project prioritization or resource augmentation for timely completion of all tasks, – Identification of key dependencies, and – An order of priority for the type of expertise and skill sets for the early hiring of exchange personnel 4
New York’s Exchange Principles and O Ops Functions F ti Promote affordable, , • Premium Tax Credits; Qualified Health Plan (QHP) comprehensive health Certification; Plan Rating System; Risk Adjustment insurance options • Website; Customer Service Operations; SHOP ‐ specific Processes; Eligibility Verification; Outreach & Consumer oriented Marketing Plan; Navigator/Broker Program; Enrollment, Billing & Collections • Governance & Oversight; Internal Administration; Transparent and Financial Management; Outreach & Marketing Plan; accountable External Reporting; Mandate Determination & Appeals It must work! • All of the above 5
Structure of Ops “Blueprint” Structure of Ops Blueprint Business Requirements (5) Core Work Process (17) 1 E 1. Exchange Set ‐ up h S t 1 1. G Governance & Oversight & O i ht 2. Internal Administration 3. Financial Management 2. Core Systems 4. Eligibility Verification 5. Premium Tax Credit Administration 6. Website & Decision Support Tools pp 7. Enrollment & Billing 8. Customer Service Call Center 9 9. SHOP ‐ specific functions SHOP specific functions 3. Communication & Outreach 10. Outreach & Marketing Plan 11. Navigator Program 12. Broker Program 6
Structure of Ops “Blueprint” (con’t) Structure of Ops Blueprint (con t) Business Requirements (5) ‐ continued Core Work Processes (17) ‐ continued 4. QHP Plan Management 13. QHP Certification 14. Plan Rating System 15. 15 Risk Adjustment Reinsurance Risk Risk Adjustment, Reinsurance, Risk Corridor (3R’s) 5. Regulation Compliance & Reporting 16. External Reporting & Consumer Protection 17. Exemption Certificate & Eligibility Determination Appeals 7
Exchange Set Up Exchange Set Up 1. Governance • Enabling legislation Enabling legislation and Oversight • Establishing legal entity and BOD • Hire Key Personnel Hire Key Personnel 2. Internal 2 Internal Administration • Meeting aggressive deadlines and operationalizing the business plan operationalizing the business plan 3. Financial require full time staff and permanent Management leadership • Process for vetting a number of policy issues and business decisions 8
Exchange Set Up (con’t) Exchange Set Up (con t) • Hire staff level personnel: p 1. Governance and Oversight – Project Managers – Finance staff (Budgets / Accounting) • Establish exchange as legal entity (Tax • Establish exchange as legal entity (Tax 2. Internal 2 I t l Administration ID, mailing address) • Locate and secure physical space p y p 3. Financial • Secure computers, office equipment Management • Employee Benefits • Establish Organizational Policies & Procedures – Purchasing contracting compliance Purchasing, contracting, compliance 9
Exchange Set Up (con’t) Exchange Set Up (con t) • Assess and implement an accounting p g 1. Governance and Oversight system • Payroll 2 Internal 2. Internal • Develop chart of accounts (backbone Administration of financial reporting) • Strong system of internal controls St t f i t l t l 3. Financial needed (underpinning of system Management needed to prevent & detect fraud, p , waste and abuse) • Financial & Management Reporting 10
Core Systems y Eligibility Verification • Centralizing eligibility verification Centralizing eligibility verification Premium Tax Credit • One Eligibility system for MAGI ‐ Administration and Cost Calculator Medicaid, Child Health Plus, BHP (if , , ( Website & Decision offered) and Exchange enrollees Support Tools (Individual and SHOP) Enrollment & Billing • Coordination with Non ‐ MAGI Call Center & Customer Service • Employer data, immigration and SHOP specific SHOP ‐ specific incarceration verification Processes 11
Core Systems (con’t) Core Systems (con t) Eligibility Verification • Tax credit and cost sharing subsidy determination Premium Tax Credit Administration & • Change in circumstances Cost Calculator • Coordination with IRS/Treasury and Coordination with IRS/Treasury and Website & Decision Issuers of QHPs Support Tools • Tax credits and subsidies will be key Enrollment & Billing enrollment driver for exchange as these enrollment driver for exchange as these Call Center & are not available outside of exchange Customer Service • Cost Calculator on website SHOP ‐ specific – Automated calculator tool must quickly, d l l l kl Processes simply, and accurately inform applicant of costs after credits and subsidies 12
Core Systems (con’t) Core Systems (con t) Eligibility Verification • NY is 1 of 11 states participating as a NY is 1 of 11 states participating as a Premium Tax Credit design partner in the Enroll UX 2014 Administration and project led by IDEO Cost Calculator Website & Decision • QHP Plan Comparisons Support Tools • Financial Disclosures Enrollment & Billing Call Center & • Source of consumer information Customer Service • Website will begin shopping g pp g SHOP ‐ specific Processes experience for many 13
Core Systems (con’t) Core Systems (con t) Eligibility Verification • Enrollment Interface Enrollment Interface Premium Tax Credit • Open Enrollment (NG); Continuous Administration and Cost Calculator Enrollment (SG) ( ) Website & Decision • Coordination of QHP enrollment rules Support Tools Enrollment & Billing • Premium Billing Aggregation (SHOP) Premium Billing Aggregation (SHOP) Call Center & • Possible Aggregation of Individual Customer Service Premiums SHOP ‐ specific Processes • Tracking and Reconciliation 14
Core Systems (con’t) Diagram of SHOP Funds Flow x x 15
Core Systems (con’t) Core Systems (con t) Eligibility Verification • Toll free 800 # mandated Toll free 800 # mandated Premium Tax Credit • Can be different for individual and Administration and Cost Calculator SHOP exchanges g Website Decision • Consumer Assistance functionality Support Tools Enrollment & Billing • Assistance with: Assistance with: Call Center & – Application Customer Service – Advance payment of tax credit SHOP ‐ specific Processes – Benefit levels available (precious metals) – QHPs offered, etc. 16
Core Systems (con’t) Core Systems (con t) Eligibility Verification • Eligibility Determination • Employer/Employee Communications Premium Tax Credit Administration and • Small Business Verification Cost Calculator • Composite / List Billing • Composite / List Billing Website & Decision • Level of standardization across QHPs Support Tools Enrollment & Billing • Enrollment Process Call Center & • Employee mid ‐ cycle changes Customer Service • Renewal Process SHOP ‐ specific • Billing and reconciliation Billi d ili ti Processes • Broker Training, Commission Payment, Account Management 17
Outreach & Marketing Outreach & Marketing • Development of a Communications Strategy Outreach & Marketing Plan • Broad ‐ based Marketing vs. Targeted segments Navigator • Varied Media Options: Program – Advertising Advertising Broker Program – PR – Media relations – Partnerships with other public or private entities P t hi ith th bli i t titi • Marketing plan must communicate the value proposition of the exchange to both the public and to all potential enrollment bl d ll l ll constituencies • Budget implications g p 18
Outreach & Marketing (con’t) Outreach & Marketing (con t) • Navigator duties: g Outreach & Marketing Plan – Educational (QHP comparison and Navigator availability of tax credits & subsidies) Program – Facilitate enrollment F ilit t ll t Broker Program – Referrals to consumer assistance – Culturally and linguistically appropriate y g y pp p • Exchange will need to select, train, certify and measure the performance of navigators f i • Must be paid by Exchange, not federal funds funds 19
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