States that control their own insurance marketplaces – called state-based marketplaces (SBMs) – are leaders in providing affordability and choice, outperforming the federal marketplace on notable markers including higher enrollment, lower premium rate hikes, more participating issuers, and successfully attracting a young consumer base. These accomplishments are especially notable given recent federal policy actions that have unsettled insurance markets and a national rise in uninsured rates.
The success of SBMs results from years of hard work spent cultivating their markets while building operational and technical systems tailored to serve their states’ consumers. Thanks to the work of these SBMs and the evolution of new technology, it is now easier (and cheaper) for states currently using the federal platform to switch and adopt the SBM model.
As new states express interest in the SBM model, they can learn much from the leaders who have pioneered implementation of this model.
Earlier this month, the National Academy for State Health Policy (NASHP) hosted a webinar with SBM leaders from Idaho, Nevada, Massachusetts, and Washington, DC to showcase some of their lessons. Highlights are featured below, and a recording and slides from the webinar are available here.
Focus on the Basics (and Avoid Scope Creep)
SBMs provide more than “shop-and-compare” websites for consumers shopping for health insurance — SBMs are dynamic business enterprises. While their main objective is to make sure that individuals have “easy access to health coverage,” SBMs must also:
- Perform a series of complicated eligibility and enrollment functions easily;
- Work with the systems of partner organizations, including carriers, Medicaid, and outreach partners; and
- Be financially sustainable.
Rather than get carried away by bells, whistles, and complex policy aspirations, SBM leaders advise that future SBMs must first focus on building a functional, sustainable system. Once a working SBM is established with a long-term financing strategy, it can always grow and evolve to perform new functions.
Prioritize the Consumer Experience
Much of an SBM’s success depends on its ability to attract and retain consumers. Over the years, SBMs have worked diligently to improve the experience of its consumers. As Massachusetts Health Connector Chief of Policy and Strategy Audrey Gasteier explained, “Marketplaces require a lot of activity on the part of a consumer,” and it is important that consumers feel empowered. Outreach is a major component of this work — from providing educational materials to in-person assistance provided by brokers, Navigators, and certified application counselors. Earned press coverage and social media are also effective tools for SBMs to quickly spread the word about their products and policy changes at low cost. Speakers also noted the importance of call centers and recommended that states equip their centers with self-service capabilities so that consumers can easily resolve common issues over the phone.
Set Clear Expectations and Timelines
Heather Korbulic, executive director of Nevada’s SBM, presented an 18-month timeline for implementation of an SBM — from passage of enabling legislation to the marketplace’s first open enrollment period. While “out-of-the box” technology and adaptable systems make it easier than ever to for a state to build an SBM leaders cautioned states not to be too aggressive in their planning and timetables. As with any large-scale project, states should anticipate delays and challenges. For example, from the start states need to work closely with federal officials from the Center Consumer Information and Insurance Oversight (CCIIO) to establish their marketplace “blueprint.” While CCIIO experts serve as an important resource for states — providing years of technical and policy expertise to help guide states — implementation of an SBM requires strict federal oversight and approvals that may cause delays that are outside of the control of a state.
Throughout the SBM implementation process, leaders emphasized the importance of maintaining transparency so that stakeholders are not deterred by unexpected delays or issues. By keeping stakeholders informed of progress and expectations, an SBM will cultivate trust and maintain relationships critical to the marketplace’s long-term success.
Relationships Are the Foundation of an SBM
Any marketplace cannot function without engagement across a mix of stakeholders, which include:
- State policymakers who will establish the marketplace;
- Federal officials who will oversee and approve its implementation;
- Insurance carriers who will sell products through the marketplace; and
- Consumers whom the marketplace will serve.
Stakeholders will have different — and sometimes conflicting — interests and it is the job of the marketplace to balance those interests in pursuit of mutual goals. Leaders underscored the importance of insurer engagement, recognizing the central role of health plans in the success of the marketplace. Establishment of an SBM will require insurers in the state to establish new business practices. A state should not underestimate the uniqueness of how each carrier operates and the time it may take for each to adapt to the new SBM system.
Establish Clear Leadership that Can Take Quick Action
A state has the flexibility to choose how to establish its SBM — either as a state agency, a non-profit, or a quasi-public-private entity. Because an SBM must be responsive to changing consumer and insurer markets and be able to readily contract with vendors to develop needed services, it is best that an SBM assume a governance structure that can enable it to act quickly. Moreover, leaders directors noted the importance of leadership to any marketplace. While operation of an SBM takes a team, it is important to have one person who is clearly designated to establish priorities, take accountability, and make decisions to get the SBM “across the finish line.”
SBMs Serve as a “Hub” for Health Reform across State Agencies.
Regardless of the specific model chosen, SBMs must be able to work across existing state agencies including Medicaid, insurance departments, and other health policy agencies. SBMs are uniquely positioned to serve consumers who range from those on the cusp of Medicaid eligibility to those accustomed to various types of commercial market coverage. To ensure smooth processes for consumers, SBMs must be able to navigate between agencies to ensure that its policies and operations are consistent with what is being promulgated by its sister agencies.
For instance, SBMs are required to generate many different types of notices to consumers, such as information related to a consumer’s eligibility for coverage programs. SBMs coordinate closely with their Medicaid agencies on the language and process for sending these notices to help reduce confusion for consumers who might otherwise receive duplicative or misaligned information from both agencies. Additionally, because SBMs serve consumers who are eligible for federal tax credits, they serve an important role in informing state and federal policymakers about how policy changes may directly impact their consumers. To serve this role, it is important that SBMs have sufficient analytic capacity to process data on their consumers and advise on the implications of changing federal and state policies.
Let SBMs Adapt Over Time
Insurance markets and marketplace consumers are not static, and SBMs must be able to adjust to changing needs and consumers. They must constantly work to engage new consumers who may be coming in and out of other coverage programs (e.g., leaving parental coverage, employer-sponsored insurance, or Medicaid), while also adapting to evolving expectations as consumers interact more and more with e-commerce and advanced technology. Through consumer surveys and testing, SBMs are constantly learning and adapting their services. One benefit of their flexible structure is that SBMs are also becoming more sophisticated and efficient in navigating this process. Some have even been able to cut operational expenses and lower the assessments they charge to carriers who sell on their exchanges, which, in turn, results in lower consumer premiums. For example, Mila Kofman, executive director of DC Health Link, estimates her SBM was able to save approximately $2 million annually by moving its data servers to a cloud-based system in 2016.
Most notably, leaders point out that each SBM has taken a unique approach in how it has operationalized its marketplace. In the process, each has learned lessons from their SBM peers — from simply sharing effective marketing strategies to full partnerships, like Massachusetts’ adoption of Washington, DC’s technology for its small business marketplace. In this spirit, speakers advised states to learn from their peers as they work through their own challenges on the road to implementing SBMs.
NASHP and the SBMs are ready and eager to help support states as they contemplate establishing their own SBMs. For additional resources about SBM models and implementation, explore NASHP’s State Exchange Resource Hub.
As states transform their health systems, many are turning to community health workers (CHWs) to improve health outcomes and access to care, address social determinants of health, and help control costs of care. While state definitions vary, CHWs are typically frontline workers who are trusted members of and/or have a unique and intimate understanding of the communities they serve. NASHP has produced a number of resources, below, to support state efforts to incorporate CHWs into their health and health equity improvement work. If you would like to suggest a resource or share your state’s efforts, please contact Malka Berro at email@example.com.
- Innovative Community Health Worker Strategies: Medicaid Payment Models for Community Health Worker Home Visits, December 2017. This case study examines Medicaid payment models from Minnesota, New York, Utah, and Washington for CHWs providing in-home services that address healthy home environments.
- Innovative Community Health Worker Strategies: My Health GPS in Washington, DC, Seeks to Achieve Sustainable Funding and Whole-Person Care, November 2017. This case study explores the financing and roles of CHWs in My Health GPS, the District of Columbia’s health home program.
- Community Health Workers: Policy Opportunities for Population Health and Patient-Centered Health Care, October 2017. This NASHP conference session highlighted state strategies and experiences in CHW financing, training, and oversight. Speakers from Oregon, Texas, and Wisconsin discussed the national CHW landscape and policy opportunities that could be explored to advance the CHW workforce in states. Please click on the speakers’ names to access their conference slides.
- State Community Health Worker Models Map, last updated August 2017. This map highlights state-level activities and policies to integrate CHWs into evolving health care systems in key areas such as financing, education and training, certification, and state definitions, roles and scope of practice. The map includes enacted state CHW legislation and provides links to state CHW associations, state agencies, and other leading organizations working on CHW policy in states. An instructional video, designed with support from the National Center for Healthy Housing (NCHH) and the W.K. Kellogg Foundation, is available to facilitate use of the map.
- Community Health Workers in the Wake of Health Care Reform: Considerations for State and Federal Policymakers, December 2015. This brief captures key themes that emerged during an October 2015 meeting of state and federal leaders to identify areas in which state and federal policy can align around the use of CHWs in transforming health systems to achieve better care, lower costs, and improved population health.
These resources were produced and updated with support from the Robert Wood Johnson Foundation, The W.K. Kellogg Foundation, the National Center for Healthy Housing, and The Commonwealth Fund.
- There were a total of 201,777 beneficiaries enrolled in District Medicaid as of July 2011. Of these, 136,003 were enrolled into managed care organizations (MCOs). Children and adults who qualify for Medicaid because they belong to an income-eligible family, as well as poverty level pregnant women and CHIP enrollees, are required to enroll into an MCO. Children enrolled in these MCOs receive physical, behavioral, and oral health services from their MCO.
- The District has developed a managed care product specifically for children with special health care needs who meet SSI eligibility requirements. Enrollees in the voluntary Health Services for Children with Special Needs (HSCSN) plan receive all EPSDT services from their well-child visit screenings to treatment services for chronic conditions and special needs. As of July 2011 there were 4,626 children enrolled in the plan.
- All managed care organizations offer transportation services and the District also operates a capitated non-emergency transportation broker program that serves children who are on fee-for-service. As of July 2011, 51,617 beneficiaries received non-emergency transportation services from that contractor.
|Medical Necessity||The District’s EPSDT manual currently defines medical necessity for EPSDT services as “medical, surgical or other services required for the prevention, diagnosis, cure, or treatment of a health related illness, condition or disability including services necessary to prevent a detrimental change in either medical, behavioral, mental or dental health status.”|
|Initiatives to Improve Access
District MCO contracts include child/EPSDT network adequacy requirements such as:
|Reporting & Data Collection||
The District requires its managed care organizations (MCOs) to compile and submit quarterly reports for HealthCheck utilization and outreach efforts. These reports are generated by MCOs using encounter data, and supplemented by other data sources.
The Department of Health Care Finance (DHCF) contracts with managed care organizations (MCOs) to provide most behavioral health care. Children with significant behavioral health needs may voluntarily enroll into a specialized MCO that serves only children with special health care needs and provides an integrated behavioral and physical health care benefit. The Health Services for Children with Special Needs (HSCSN) Plan is a managed care organization that focuses on the SSI/SSDI child population. Enrollment in the plan is voluntary; children who do not choose to enroll in the plan remain in fee-for-service Medicaid.
Integrating primary care with developmental, behavioral and oral health care Physicians are expected to screen for developmental and behavioral health issues within the standard well-child visit; the HealthCheck Manual and a collection of screening guidelines, tools, and recommendations provided for District physicians offer guidance on performing these and other screens as part of the well-child visit. In 2013, the DHCF partnered with Georgetown University and The National Alliance to Advance Adolescent Health to develop new training modules on transition issues for pediatricians on its HealthCheck website, including modules on mental health, autism spectrum disorders, and substance use and abuse.
|Supporting to Providers and Families||
Support to Providers:
The HealthCheck website portal provides education, resources, and online training on EPSDT to the provider community. The District has also adopted a version of the Bright Futures curriculum as the foundation for its EPSDT benefit. This guidance has been incorporated into HealthCheck information and provider materials. The website is not only intended for providers, but also for government agencies serving children and families as well.
Support to Families:
Since its creation, the HealthCheck portal has been expanded to include educational and training resources for families and District government agencies.
All MCOs (including the Health Services for Children with Special Needs MCO) also provide outreach and information to families on the EPSDT benefit.
The Health Services for Children with Special Needs (HSCSN) managed care plan provides comprehensive services to children, most of whom have an SSI-level of disability. In addition to a broad set of benefits available, the plan is required to coordinate with other services and systems, including Individuals with Disabilities Act (IDEA) services, mental health and substance abuse services, child protective services, and other systems that can involve transitions for children with special health care needs, such as Title V.
Contract and plan provisions for HSCSN managed care plan require that the MCO provides all enrollees with a Care Coordinator, whose responsibilities include:
In 2004, the District developed a dental periodicity schedule and a plan to improve provider participation, training, coordination of dental services and outreach. The schedule follows the American Academy of Pediatric Dentistry’s Periodicity Schedule oral health recommendations in consultation with the local dental community.
The Department of Health Care Finance works closely with the District’s Pediatric Oral Health Coalition to improve pediatric dental services for children in Medicaid. As of FY 2014, the District implemented payment for fluoride varnish services by primary care providers in an effort to increase the number of young children receiving oral health services. The District’s HealthCheck provider training portal began offering a training on fluoride varnish as well.
Federal Support: The District of Columbia has received a planning grant from the Centers for Medicare & Medicaid Services (CMS) to develop a state plan amendment to implement Section 2703 of the Affordable Care Act (ACA), establishing health homes for Medicaid enrollees with chronic conditions. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
Last Updated: April 2014
The PCO and PCA in the District together were able to document shortage areas and develop and implement the DC Health Professional Recruitment Program, a program that pays off the loans of health professionals who agree to work in DC. Also, they have had great success with the Medical Homes Initiative. By partnering with the mayor and other key players in DC, this program was created to improve the health of the District’s low-income population and reduce the cost of health care delivery by increasing clinic space by 200,000 square feet and providing high quality care to the most vulnerable DC residents.
In December 2006, the District of Columbia Council passed the Medical Malpractice Amendment Act of 2006, A16-0619, which became effective March 2007. The Act mandates three (3) reporting requirements effective July 1, 2007. The Health Regulation and Licensing Administration is currently in the process of drafting regulations. As of April 2009, interim guidelines are available for the Medical Malpractice Amendment Act of 2006.
The District of Columbia’s ABCD Screening Academy Project improves the quality and efficiency of health care services for children and families by improving state policy and supporting providers in the adoption of structured screening as part of well child care. Currently, ABCD staff are partnering with stakeholders to improve linkages between primary care and other child and family service providers by designing and implementing a web-based case management system. Specifically, the ABCD Screening Academy project in the District of Columbia activities included:
- Developing comprehensive reimbursement policies for 96110 and 96111 codes which are reimbursed in addition to the EPSDT visit.
- Creating a universal referral form which includes an Early Intervention Disclosure/Consent Form as well as a fax back option so that primary care providers are informed of the status of their referral.
- Hosting trainings and informational workshops for primary care providers and Part C regarding Medicaid policies.
- Sustaining the improvements to preventive primary care services by the designing of a Special Education Data System, a comprehensive web-based application that will enable information sharing and effective state reporting.
- Spreading improvements through a pilot case management program designed to test service delivery models and promote linkages.