MHBE-Overview-of-the-Producer-Authorization-Process - Maryland ...

Producer Information Session
Maryland Health Connection Update:
Steps to Become an Authorized Producer
A service of Maryland Health Benefit Exchange

Today’s Agenda
Producer Information Sessions – Overview
Background on Maryland Health Benefit Exchange
Maryland Health Connection
– Individuals & Families
– Small Business Health Options Program (SHOP)
SHOP Policies
Consumer Assistance
Authorized Carriers
TPA Certification Program
Producer Authorization – “3 Step Process”
Ways to Get More Information

Producer Information Sessions
The Maryland Health Benefit Exchange (MHBE) is hosting a series of
Producer Information Sessions to help producers prepare for steps
that are required to become authorized to sell plans on Maryland Health
Connection.
Topic #1: Overview of the MHBE Producer Authorization Process
– June 28 th
– July 3 rd
Topic #2: The Producer Authorization Application
– July 24 th
– July 26 th

Background
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Overview of Maryland Health Connection
The Patient Protection and Affordable Care Act requires each state
to establish a “health insurance exchange” by 2014
A marketplace where individuals and small businesses explore,
compare and enroll in health insurance and public assistance
programs as well as access federal tax credits and cost-sharing
subsidies
States had a choice to establish a state-based exchange, join a
partnership or the federally-facilitated exchange; Maryland opted to
establish a state-based health insurance exchange
Maryland’s exchange is called Maryland Health Connection
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Why It’s Important to Maryland
Expands access to health insurance for 730,000
Marylanders (13% of Maryland) currently without health
insurance
– Gives individuals access to primary care physicians,
preventive services
Provides federal subsidies for individuals up to 400% of FPL
to pay for health insurance premiums
– Infuses $600 million in federal subsidies into the State of
Maryland by 2015 NEW funds in health care system
Lowers uncompensated care costs in the healthcare system
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Stakeholder Engagement
Policy decisions have been made through an open, public and
transparent process with stakeholders representing Maryland’s
diversity from across the state
Advisory Committees have been leveraged to address key
topics:
– Navigator and Consumer Assistance / Advertising
– Market Rules and Risk Selection / Operating Model
– SHOP Exchange
– Financing the Exchange
Stakeholder representation included: producers, health
insurance industry, providers and associations, community
members, advocates, community-based organizations,
academia, business owners and leaders, local chamber officials,
consumers, consultants

Enabling Legislation
Maryland Health Benefit
Exchange Act of 2011
• GOVERNANCE MODEL & STUDY
PROCESS
• Established the Maryland Health
Benefit Exchange as a public
corporation and independent
unit of state government
• Established Nine-member Board
of Trustees
• Created Executive Director
position
• Required the public study
process
Maryland Health Benefit
Exchange Act of 2012
• POLICY & INFRASTUCTURE
• Operating Model
• Design of Small Business Health
Options Program (SHOP)
• Outreach and Consumer
Assistance Program
• Insurance carrier rules
• Financing study process
Maryland Health Progress Act
of 2013
• IMPLEMENTATION
• Medicaid expansion
• Dedicated funding stream for
financing
• Gradual transition of MHIP
enrollees into Maryland Health
Connection coverage
• Flexibility for State reinsurance
wrap-around program
• SHOP rules for employer
premium contributions
• Continuity of care for
Marylanders
• Continued public engagement
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Maryland Health Connection –
a service of the Maryland Health Benefit Exchange

What is Maryland Health Connection
One single entry point for a variety of insurance
options
– Medicaid
– Commercial insurance
“No wrong door” approach to insurance coverage as
defined by CMS
Insurance options for individuals, families and
small businesses
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Maryland Health Connection
Marketplace for Individuals & Families
Individuals and families have access to Medicaid and
commercial plans
Offers tax subsidies and cost sharing reductions to
individuals and families to make commercial plans affordable
– Only place individuals can access subsidies
– Federal government will pay a portion of costs for health
insurance for people who earn up to 400% of FPL
– Cost sharing reductions are available to individuals under
250% of FPL
Individual Open Enrollment: October 1, 2013 - March 31, 2014
– Coverage Effective: January 1, 2014
– Annual open enrollment occurs starting in October of each year
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Individual Marketplace: Enrollment Flow
Application
Eligibility
Determination
Tax Credit
Eligibility
Plan
Shopping
Initial
Payment
Collection
Confirmed
Coverage
Notify
Carriers
Consumer completes
online application for
insurance coverage.
Streamlined
application to allow
for a “no wrong door”
approach.
If not eligible for
Medicaid,
Consumer is
evaluated and
notified of
eligibility for tax
credits.
Consumer is able to
select from available
plans based on
personal
preferences.
Consumer is able
to make the initial
premium payment
directly through
Maryland Health
Connection.
Maryland Health
Connection will
display a message
to the consumer
for coverage start
date.
Maryland Health
Connection will
send a file to
carrier (s) to
notify them of
enrollment
information and
of premiums
collected
Individual Exchange Administration
• Initial Premium billing
• Carrier payment
• On-going eligibility / enrollment management
• Enrollment and funds flow reconciliation
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Maryland Health Connection
Marketplace for Small Businesses
Maryland Health Connection will have a Small Business Health
Options Program (SHOP) for small businesses and their
employees
The Small Business Health Options Program (SHOP) is a
competitive private health insurance marketplace where small
businesses and their employees will have access to affordable
coverage and a choice of insurance plans
Small businesses with up to 50 employees may participate
– In 2016, the ACA modifies the definition of small group to 100
employees
SHOP supplements the existing market…SHOP does not
replace it!!
– Small employers will still be able to purchase insurance outside of the
SHOP
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Maryland Health Connection
Marketplace for Small Businesses
Employer Benefits
– Simple, streamlined administration
• Online Adds & Drops
• Online Billing & Payment
• Phone & Online Support
– Online tools available to help employers predict costs
– The ability to continue to work with brokers and TPAs
– Many small employers will qualify for tax credits
Employee Benefits
– A wider range of plans to choose from
– Comparison tools to help select plans
– Online plan enrollment and account management
SHOP Open Enrollment: January 1, 2014
– Coverage Effective: March 1, 2014
– Annual open enrollment is based on the renewal date of the small business
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Tax Credit Eligibility
2010-2013: Maximum tax credit for small employers is 35% of
the qualified premium for health insurance for employees
– Maximum tax credit for small tax-exempt employers
(charities) is 25%
January 1, 2014, rate increases to:
– 50% tax credit for small employers
– 35% for small tax-exempt employers (charities)
Can be carried back and forward to other tax years
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Tax Credit Eligibility Examples
Fewer than 25 full-time equivalents, with average wages of less
than $50,000 per year
Provide 50% of single (not family) coverage for each employee
Calculations are made on a sliding scale
Tool available on IRS website
– http://www.irs.gov/uac/Small-Business-Health-Care-Tax-Credit-for-
Small-Employers
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SHOP Marketplace: Enrollment Flow
Eligibility
Determination
Employer
Plan Set-up
Estimated
Quote
Employee
Enrollment
Validate
Group
Notify
Carriers
Employer is evaluated
for eligibility to
purchase from SHOP
based on
demographic
information.
Employer selects a
metal level (Employee
Choice) or a carrier
(Employer Choice)
and sets defined
contribution amount.
SHOP provides an
estimated quote
based on employer
choices and employee
census (age, income,
etc.)
Employees make
plan selections
with information
on employer
contribution and
their expected
cost
Validate that all
requirements for
the employer (e.g.
minimum
participation,
creditable coverage
for employees)
have been met
Notify carriers to
contract with
employer and
start coverage
for employees
SHOP Administration
• Premium aggregation and billing
• Carrier payment
• On-going eligibility / enrollment management
(employee adds, deletes, life changes, etc.)
• Enrollment and funds flow reconciliation
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SHOP Policies

SHOP Marketplace
Open Enrollment & Effective Dates
Open enrollment for Maryland’s SHOP will begin
January 1, 2014.
– March 1, 2014 will be earliest effective date available
to employees of small businesses that purchase
insurance through the SHOP marketplace.
– SHOP annual open enrollment will then be based on
each group’s renewal date.
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Two Options for Small Employers:
Employer Choice vs. Employee Choice
Carrier
A
Carrier
B
Carrier
C
Carrier
D
Carrier
E
Carrier
F
Platinum
Gold
Silver
Employer Choice
Employee Choice
Bronze
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SHOP Eligibility
Counting Methodology
Small businesses with up to 50 employees may participate in the
SHOP
The employee counting methodology impacts whether a group will be
eligible to purchase on the SHOP – Maryland Exchange Board
approved the FTE aggregation method consistent with federal rules for
tax subsidies
Employers can decide whether to offer coverage to full time employees
or all employees
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SHOP Minimum Participation
The minimum participation requirement is 75% in
the SHOP for employer and employee choice.
Waiver Reasons
– MHBE will be soliciting public comment to help
determine waiver reasons that should be used to
exclude employees from the 75% participation
count. Information about the public comments
process will be located on www.MarylandHBE.com.

Employer Contribution
The Maryland Health Progress Act of 2013 establishes three
defined contribution options for small employers who purchase
from the SHOP:
– No Contribution
– Percent defined contribution - Small employers could elect to
make a percentage contribution based on a reference plan at the
desired metal level in the SHOP.
– Employees pay the same amount - Small employers could select
a reference plan and then make a contribution to each employee
that would ensure all employees contribute the same amount by
coverage level and job class.
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Consumer Assistance Program

Projected New Enrollment
SHOP
New Medicaid
Individuals/Families on
Maryland Health Connection
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Consumer Assistance Program
Multiple resources will be available for consumers who need assistance with
understanding insurance options.
Online at www.MarylandHealthConnection.gov
– Shop & Compare Options
– Enroll
In-person Assistance:
– Connector Program
• Navigators
• Assisters
– Application Counselors
– Insurance Producers (Brokers/Agents)
– Captive Producers
Consolidated Services Center (call center)
– Customer service
– Application and enrollment assistance
– Translation services
– TTY for the hearing impaired
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Overview of the Connector Program
Formerly called the Navigator Program
The Connector Program has two components
– Navigators: made up of Certified Individual Navigators and Licensed
SHOP Navigators
– Assisters: made up of Assisters who will perform Outreach and Education
duties and facilitate eligibility determinations and Non-certified personnel
who will provide support services
MHBE has awarded six Connector Entities in six distinct
geographic regions to implement the Connector Program in their
regions
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Consumer Assistance Roles
Navigators will:
– Conduct public education and outreach as required by the Affordable
Care Act
– Distribute fair and impartial information
– Facilitate enrollment in health plans
– Provide referrals for grievances, complaints and questions
– Provide information in a culturally and linguistically appropriate manner
– Maintain expertise in eligibility, enrollment and program specifications
– Refer insured small groups and individuals back to producers
Assisters will:
– Conduct public education and outreach;
– Facilitate eligibility determination for subsidies, Medicaid, and MCHP;
– Facilitate and provide ongoing support
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Consumer Assistance Roles
Application Counselors:
– New role introduced by U.S. HHS to allow for additional resources to
assist
– Facilitate enrollment in health plans
– Act in the best interest of the enrollee
– Disclose any potential conflicts
– Receive no funding from the MHBE
Insurance Producers (Agents/Brokers):
– Serve an important role in the Exchange
– Continue to work directly with small group customers and Individuals
– Register to become authorized to sell QHP inside the Exchange
– Be compensated directly by the carriers (as they currently are)
– Receive training from the Exchange
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Consumer Assistance Roles
Captive producers:
– may transition carrier’s existing individual enrollees into Maryland Health
Connection qualified plan, and may provide enrollment assistance to
individuals who contact the carrier;
– must act in best interests of consumer;
– must disclose their employment with carrier;
– are subject to same restrictions as navigators; and
– are subject to same licensing and MHBE authorization requirements as
authorized producers;
– Carriers must:
• document and retain records of such disclosures for three years;
• provide disclosure records and updated lists of captive producers to Exchange;
Non-compliance with requirements is grounds for sanctions for both captive
producer and carrier;
Program must be administered in non-discriminatory manner without adverse
selection impact; and
Program to be sunset after three years, with study and report in 2015 on its effect
and whether or not it should be continued.
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Consumer Assistance Roles
Consolidated Service Center:
– Inbound Call Center (Toll-Free Hotline) linked from
www.MarylandHealthConnection.gov
– Language Line/Translation Services
– TTY (Hearing Impaired)
– Extended Hours During Open Enrollment
– Coordination with Insurance Carriers and Connector Entities
– Scheduled Opening: August 2013 (with launch of
advertising campaign and social media launch)
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Authorized Carriers

Authorized Carriers
Maryland has adopted a strategy for 2014-2015 that allows any willing carrier to offer
qualified health plans on Maryland Health Connection as long as they meet federal and
state requirements. This approach will foster competition in the marketplace and help
to build stability for Maryland Health Connection.
Medical
• Aetna
• CareFirst
• Coventry
• Evergreen (CO-OP)
• Kaiser
• United HealthCare
•Aetna Dental
•BEST Life
•CareFirst
•Coventry
•Delta Dental
•DentaQuest
•Dominion Dental
•Guardian
•Metropolitan Life
•United Concordia
Stand-Alone Dental
List reflects names of carriers by parent company name.
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Product Summary
Plans offered on Maryland Health
Connection will include:
– Medical Only Plans
– Medical Plans with Embedded
Dental
– Stand-Alone Dental Plans
Carriers are required to obtain
approval from the MIA on plans
before they can be certified by MHBE.
Carrier applications indicate that they
intend to offer PPO, HMO, EPO, POS
products.
Additionally, carriers have noted that
they intend to offer plans across all
metal tiers for the Individual and
SHOP marketplaces.
Essential Health Benefits
Ambulatory Services
Emergency Services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder
services
Prescription drugs
Rehabilitative and habilitative services and
devices
Laboratory services
Preventive and wellness services and chronic
disease management
Pediatric services including oral and vision care

Carrier Participation Update
Multi-State Plan Program
Section 1334 of the Affordable Care Act directs the U.S.
Office of Personnel Management (OPM) to contract with
private health insurance issuers to offer at least 2 multistate
plans to individuals and small business in each state.
MHBE and MIA are working with OPM to develop
procedures for authorizing multi-state plan issuers and
certifying their plans.
It is expected that Maryland will have at least one multistate
plan issuer in year 1.
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TPA Certification Program

TPA SHOP Certification Program
Third Party Benefit Administrators (TPAs) play a key
role in ensuring Marylanders have access to
affordable coverage options.
As part of the Small Business Health Options Program
(SHOP), licensed TPAs can become certified by the
Maryland Health Benefit Exchange to perform several
business functions including:
– Qualified health plan comparison and selection by
employers and employees
– Administration of enrollment and eligibility changes
– Premium billing and collections
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TPA Program Options
Three distinct programs allow third party administrators choose
how they want to participate in the SHOP Exchange
Program 1: SHOP Alternate Online Market Place and
Back Office Services
– The TPA will have their own system that will replicate
the Maryland Health Connection online shopping
flows in addition to management of back-office
administration.
Program 2: SHOP Back Office Administrative Services
– The shopping experience will take place in Maryland
Health Connection and the TPA will be responsible
for back-office administration in their own system.
Program 3: SHOP Online Administrative Services
– Both the shopping experience and the back office
administrative activity take place in Maryland Health
Connection.
Program 3
Program 2
Program 1

TPA Certification Program
Organizations that wish to become certified as TPA
business partners with MHBE must be approved
through the MHBE Certification Process.
The certification process is under development in
cooperation and will consist of four components:
1) TPA Application Package
2) Systems & business operations validation
3) Training
4) Certification from MHBE
The application package and agreements will be
available on the MHBE website in July 2013.
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Producer Authorization:
The 3-Step Process
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The MHBE Producer Program
Maryland has designed a prominent role for producers as it works to
create Maryland Health Connection.
Producers will be key partners to help individuals and small businesses
get access to plans offered on Maryland Health Connection.
MHBE is designing a Producer Program to ensure producers receive
information and can provide input.
Proactive
Communication
Planning &
Feedback
Training &
Authorization
Book of Business
Management
Tools
Service &
Support

Producer Program
Planning & Feedback
– Producer Advisory Council
Communication Tools
– Newsletter
– Website

Producer Authorization
Steps to Producer Authorization
MHBE is developing a 3-step process for Producer Authorization.
Producers must complete all 3 steps in order to sell plans offered
through Maryland Health Connection.
1. Submit the
MHBE
Application
2. Complete
MHBE Training
3. Receive MHBE
Authorization

Producer Authorization
Criteria for Applying
Licensed Health Producers can apply as long as they meet the following criteria:
– Holds a current license that qualifies the producer to sell health benefits in
Maryland
– Is in good standing with no outstanding consumer complaints
– Maintain a sufficient level of errors and omission coverage as required by carriers
– Not excluded from participation in federal health programs
– Not debarred from State contracts
– Have completed MHBE required training and authorization process
– Agree to present all plans from all participating carriers and disclose appointment
status to consumers
– Agree to privacy and security standards established by the MHBE
– Agree to work cooperatively with Connector Entities/Navigators, as applicable
– Agree to immediately report concerns or complaints from employers, employees
or individual consumers
– Agree to complete re-training education requirements.
Both resident and non-resident producers are eligible to apply

Producer Authorization
Requirements
Every licensed producer who wants to discuss plans
offered on Maryland Health Connection with individuals
and small businesses must complete the 3 steps of
authorization.
Only MHBE offered training will allow licensed producers to
get authorized to sell plans offered on Maryland Health
Connection.
Out of state exchange authorization will not be accepted as
a replacement for Maryland authorization.
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Producer Authorization
Application
The Producer authorization application will be
available online
MHBE will send out notification once the authorization
application is available
Additional Producer Information Sessions will be
conducted at the end of July regarding application
procedures
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Producer Authorization
Training
The MHBE will begin to offer training sessions for producers in August
2013
– Only training offered by MHBE will be accepted for authorization
– Details of the training are being developed
– The training sessions will be up to eight hours and offered in a
conference format
MHBE is working with Maryland Insurance Administration to determine if
CE credits can be given for Maryland Health Connection Producer
training
Information on available training sessions will be posted on
www.MarylandHBE.com on the Insurance Producer page
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Producer Authorization
Notification of Authorization
After a producer submits an authorization
application and completes the required training,
MHBE will provide written notification to
producers indicating authorization
The first round of notification will be going out in
September
49

Producer Authorization Expiration
Producer Authorization Expiration
Producer authorization expires two years after the
date it is issued
– MHBE will notify authorized producers 60 days
before expiration
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Producer Appointments
Carrier Appointments
Carrier appointments are NOT a pre-requisite of producer authorization.
Interim procedures provide rules for carriers when appointing producers:
– A carrier must appoint an authorized producer within 10 business days of receipt
the request from the producer
– A carrier must appoint every authorized producer
• unless reasons specified under 31112(e)(1), Annotated Code of Maryland
– A carrier can not deny appointment based on production volume
– A carrier can not impose a production requirement
– A carrier must allow authorized producers to discuss all Maryland Health
Connection plans with or without an appointment
– A carrier must provide a basis for denial to the authorized producer within 10
business days
– Dispute resolution will be managed by the MIA
• While the dispute is being reviewed by the MIA, the producer can continue to sell and
enroll individuals and small businesses
– A carrier can limit the scope of an appointment to only Maryland Health
Connection
– A carrier must provide information on their producer register upon request of the
MHBE
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Producer Compensation
Producer Compensation
Carriers will continue to be responsible for compensation of producers that sell
plans on Maryland Health Connection.
Carriers will continue to develop their own models of compensation for producers.
Compensation models must not result in the disruption of consumers’ access to
qualified plans, steering of consumers away from appropriate insurance offerings,
or threaten the viability of Maryland Health Connection.
Carriers are expected to develop equivalent compensation and incentives for
sales inside and outside of the state-based exchange.
Carriers are required to collect and maintain producer compensation data
including agreements, policies, procedures, programs and other information
regarding producer compensation. Carriers must provide this information to the
Maryland Insurance Administration upon request.

Current Procedures under Discussion
Producer of Record
– Individual Exchange
• Producer of Record change - only during open enrollment or at a
special enrollment time
– SHOP Exchange
• Must be initiated by the group
• One Producer of Record change per year
Book of Business Management Tools
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Producer Support Model
The Producer Operations Team
Rebecca G. Bayne – Manager, Producer Operations
Christopher Yeiser – Business Operations Specialist
Becky Smith – Business Operations Specialist
Email us at Producer@MarylandHBE.com

Ways to Get More Information!
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Online Resources
MarylandHealthConnection.gov
Sign Up for Email Updates
Sign Up for Text Updates: Text “Connected” to
69302
Get information on insurance resources
available to help now
Plans Available
Individuals – October 1, 2013
SHOP – January 1, 2014
MarylandHBE.com
Producer Training &
Authorization Information
Meeting Information
RFP Announcements
Job Information
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Thank you!
For questions on the information contained in this presentation,
please contact:
Rebecca Bayne
Manager, Producer Operations
Maryland Health Benefit Exchange
Producer@MarylandHBE.com
www.MarylandHealthConnection.gov
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