Florida’s Marketplace v.An Exchange

Rose M. Naff, CEO

Florida Health Choices, Inc.

EstablishmentFlorida’s Marketplace Exchange

Established by State of Florida -State-U.S. Department of Health and Human Services

Method of Establishment

Florida Law408.910 Florida Statues

-State Law-Executive Order-Default

Organization type Not-for-profit established by State -State Agency-Independent State Agency-Not-for-profit established by State-Federal Agency

Models N/A -State Only-State Only Late Election-Partnership-Federal Only-Federal with Not-For-Profit-Transitional

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Exchange Organizational TypesExchange

OrganizationsEntity Other Requirements

State Agency State Medicaid agency or any other State agency

Independent State Agency Governing board required Public Meetings Charter or By Laws At least one consumer representative Majority not insurers Relevant experience

Not-for-profit established by State

Incorporated under, and subject to laws of one or more States

Governing board required Public Meetings Charter or By Laws At least one consumer representative Majority not insurers Relevant experience

Federal Agency U.S. Department of Health and Human Services

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Exchange Models and TransitionsExchange Model

Operational Responsibility

Other Requirements

State Only State Approval standards apply12 months advance approval

State Only Late Election(seeks approval after 1/1/2013)

U.S. Department of Health and Human Services

Joint plan to transition to State OnlyApproval standards apply12 months advance approval

Partnership U.S. Department of Health and Human Services

Partnership agreement requiredState may perform one of more of the following functions: Plan Management “Certain” consumer service functions

Federal Only U.S. Department of Health and Human Services

Federal with Not-For-Profit U.S. Department of Health and Human Services

State Only Ceases Operation State 12 months advance noticeJoint plan to transition to Federal Only

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EstablishmentFlorida’s Marketplace Exchange

Purchasing Type Open -Open -Active purchaser/selective contracting

Market Type Individual (limited)Small Business

Individual Small Business (SHOP)

Market Approach One Entity -One Entity-Multiple Entities

Market Administration

Combined -Combined-Separate

Statewideness Statewide -Statewide-Regional (Multi-state)-Subsidiary

Federal Approval N/A Required:Exchange BlueprintOrganizational Readiness

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GovernanceFlorida’s Marketplace Exchange

Responsible party

Board of Directors -State Agency Secretary-Board of Directors-Federal Agency Secretary

Appointed by Determined by the State as: Governor (4) Senate President (4) House Speaker (4)

-Determined by the State-U.S. President

Make Up 12 voting members 3 ex-officio members

At least one consumer representative

Experience Though not required by law, current members have experience in health benefit administration, health care financing, health plan purchasing, health care delivery system administration, public health and the uninsured.

Majority must have experience in health benefit administration, health care finance, health plan purchasing, health care delivery system administration, public health, health policy issues related to small group and individual markets and the uninsured.

Appointment Limitations

May not include insurers, health insurance agents or brokers, health care providers, HMOs, prepaid service providers, or any other entity, affiliate or subsidiary of eligible vendors.

No limitation on appointments; However, A majority may not include representatives of health insurers, agents or brokers or any other individual licensed to sell health insurance

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Governance PrinciplesFlorida’s Marketplace Exchange

Charter or By Laws Publicly adopted, available on website Must be publically available

Ethic Standards Publicly adopted, available on website Must be publically available

Conflict of Interest Standards

Publicly adopted, available on website Must be publically available

Financial Disclosure Standards

Not addressed Must be publically available

Accountability and Transparency Standards

Subject to Florida Sunshine and Public Record laws

All board, committee, subcommittee, and steering committee meetings are public meetings

Meeting materials are available to the public in advance

Must be publically available

Federal Review N/A HHS may periodically review accountability structure and governance principles

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Consumer ToolsConsumer Tool Florida’s Marketplace Exchange

Call Center Required Required

Internet Website: Required Required

Plan comparison Design Element Required

Financial Information Design Element Required

Assistance Info Design Element Required

Determines Eligibility Required Required

Plan Selection Design Element Required

Calculator Design Element Required

Product/Vendor info Required Required

Accessibility Design Element Required

Section 125 Assist Required

Consumer Assistance Required Required

Marketing/Outreach Required Required

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Assistance ProgramsAssistance Program Florida’s Pathfinders Exchange Navigator

Established by Florida Health Choices Federal law

Administered by Florida Health Choices -State Exchange-Federal Exchange-Under Partnership option, State may administer the Navigator Program under the direction of the Federal Exchange

In Consultation with -Agent Steering Committee-Division of Agent and Agency Services-Professional associations

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Grantees N/A Entity or Individual must:-Demonstrate ability to carry out duties-Have or can establish relationships with likely eligible employers and individuals-Meet licensing, certification or other standards, if any-No conflict of interest during the term-Comply with privacy and security standards

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Assistance Programs

Eligibility Florida’s Pathfinders Exchange NavigatorsEligibility Criteria Health Insurance Agents

licensed by the State of Florida Community, consumer-focused nonprofit and at least one of the following: -Trade, industry, and professional assoc.-Commercial fishing, ranching and farming organizations -Chambers of commerce-Unions-Resource partners of the SBA -Licensed agents and brokers-Other public or private entities or individuals

Prohibited N/A No health insurers or their subsidiariesNo association that includes members of, or lobbies on behalf of, the insurance industry

Eligibility Verification Data interface between Florida Health Choices and Division of Agent and Agency Services

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Other N/A Application Assisters

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Vendors v. Qualified Health Plans

Plans Florida’s Marketplace Exchange QHPLevels N/A Bronze

GoldPlatinum

Covered Benefits As filed and approved by the Office of Insurance Regulation

A benefit plan selected by the State

Rates As filed and approved by the Office of Insurance Regulation

Plan Management

Rate Changes As filed and approved by the Office of Insurance Regulation

Justification required

Other Services As approved by Florida’s Marketplace

N/A

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Employers: Marketplace v. SHOPEmployers Florida’s Marketplace Small Business Health Options

Program (SHOP)

Employer eligibility criteria established by:

Board of Directors Federal Law

Employer Size 4-50 1-50 or 1-100

Eligibility determinations Florida’s Marketplace Exchange

Enrollment Period Rolling Rolling

Growing employer May continue May continue

Multi-state employers 85% must reside in Florida May participate in multiple SHOPS

Participation requirements Participation 50%Employer contribution 50%

Minimum participation is an optionMinimum contribution not an option

New Hires Employer’s waiting period No waiting period

Renewal Annual renewal Annual renewal

Tax Implications May reduce taxes Tax credits

Penalties None Yes

Premium payments Employer to Marketplace Employer to Exchange

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Employees: Marketplace v. SHOP

Employees Florida’s Marketplace Small Business Health Options Program (SHOP)

Employee eligibility criteria established by:

Board of Directors Patient Protection and Affordable Care Act

Criteria Any individual employed

Enrollment 60-day period

Affordability Test None 9.5% of household income

Fail Affordability Test N/A Eligible for advance payment of tax credits. Move out of employer group in the SHOP and into Individual Exchange.

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