1
00:00:00,049 --> 00:00:00,600
Hey, everybody.
2
00:00:00,630 --> 00:00:01,719
Welcome to Regulatory Joe.
3
00:00:01,839 --> 00:00:03,699
I'm Joe Boyle, president of ClearFile,
4
00:00:03,789 --> 00:00:05,119
and on today's episode, we'll be
5
00:00:05,153 --> 00:00:06,883
discussing the shift to state-based
6
00:00:06,883 --> 00:00:09,183
exchanges and why that's picking up speed.
7
00:00:09,243 --> 00:00:10,903
So before we get into the shift, we'll
8
00:00:10,903 --> 00:00:13,263
just do a quick recap on some terminology.
9
00:00:13,443 --> 00:00:15,583
What is a federally facilitated exchange?
10
00:00:15,676 --> 00:00:17,326
An FFE is where an issuer
11
00:00:17,326 --> 00:00:18,996
traditionally files through CMS,
12
00:00:19,033 --> 00:00:21,003
utilizes and relies on them for
13
00:00:21,043 --> 00:00:22,853
enrollment and marketplace functions.
14
00:00:22,943 --> 00:00:24,453
When we talk about a full state-based
15
00:00:24,453 --> 00:00:26,133
marketplace, that's where a state
16
00:00:26,173 --> 00:00:28,573
exchange manages all operations within
17
00:00:28,573 --> 00:00:30,463
the marketplace, including enrollment
18
00:00:30,463 --> 00:00:32,003
and billing on behalf of that issuer.
19
00:00:32,405 --> 00:00:34,315
A state-based exchange operating
20
00:00:34,315 --> 00:00:36,215
on a federal platform, otherwise
21
00:00:36,215 --> 00:00:39,450
known as an SBE-FP, is a traditional
22
00:00:39,450 --> 00:00:41,590
one-year transitionary period that
23
00:00:41,600 --> 00:00:43,670
allows state-based exchanges to become
24
00:00:43,670 --> 00:00:45,960
prepared with readiness, staffing,
25
00:00:46,000 --> 00:00:48,630
operations to then be able to handle
26
00:00:48,630 --> 00:00:50,540
the volumes of enrollment, the volumes
27
00:00:50,540 --> 00:00:52,170
of billing, the volumes of functions
28
00:00:52,170 --> 00:00:54,120
that members will create during the
29
00:00:54,130 --> 00:00:56,340
influx of enrollment after an issuer
30
00:00:56,350 --> 00:00:58,090
has completed the filing process.
31
00:00:58,319 --> 00:01:00,699
So if you put the ACA on a timeline from
32
00:01:00,699 --> 00:01:02,949
the inception of QHPs, there was really
33
00:01:02,949 --> 00:01:06,149
14 states that embraced the ability to
34
00:01:06,219 --> 00:01:07,989
either transition by way of a state-based
35
00:01:07,989 --> 00:01:10,419
marketplace or state-based exchange
36
00:01:10,479 --> 00:01:12,359
or become a full state-based exchange.
37
00:01:12,669 --> 00:01:14,079
When we fast-forward the clock
38
00:01:14,079 --> 00:01:15,689
to today in current time, those
39
00:01:15,699 --> 00:01:17,609
statistics have grown immensely.
40
00:01:17,659 --> 00:01:19,199
And when we fast-forward the clock to
41
00:01:19,199 --> 00:01:21,569
today for the most recent states looking
42
00:01:21,569 --> 00:01:23,069
to convert to become a state-based
43
00:01:23,069 --> 00:01:26,099
exchange for plan year 2027, Oregon
44
00:01:26,129 --> 00:01:27,939
is bringing the total industry pool
45
00:01:27,969 --> 00:01:29,769
up to about forty-three percent of all
46
00:01:29,799 --> 00:01:32,289
jurisdictions implementing this as a
47
00:01:32,289 --> 00:01:34,499
core principle for future plan years.
48
00:01:34,739 --> 00:01:37,409
If we walk back recent pace of transition
49
00:01:37,409 --> 00:01:39,099
history, we can look at a few states
50
00:01:39,099 --> 00:01:40,879
that have also followed this trajectory
51
00:01:41,059 --> 00:01:42,399
over the past couple plan years.
52
00:01:42,472 --> 00:01:43,992
Virginia moved to become a
53
00:01:43,992 --> 00:01:45,212
state-based exchange during
54
00:01:45,212 --> 00:01:46,152
plan year twenty twenty-four
55
00:01:46,623 --> 00:01:48,553
Georgia for plan year twenty twenty-five,
56
00:01:48,743 --> 00:01:50,243
Illinois for plan year twenty twenty-six.
57
00:01:50,696 --> 00:01:52,166
Like we mentioned Oregon for Plan
58
00:01:52,166 --> 00:01:54,536
Year 2027, that really sets the tone
59
00:01:54,536 --> 00:01:56,606
for an even faster pace as we enter
60
00:01:56,606 --> 00:01:58,176
and start planning strategically
61
00:01:58,396 --> 00:02:00,916
into Plan Year '29, '30, and so on.
62
00:02:01,242 --> 00:02:03,232
And when we even walk back a timeline
63
00:02:03,232 --> 00:02:05,572
for states such as Oklahoma entering
64
00:02:05,572 --> 00:02:08,022
this SBE-FP process in plan year 2026,
65
00:02:09,312 --> 00:02:11,202
now looking for a full conversion to a
66
00:02:11,202 --> 00:02:13,752
State-based Exchange in plan year 2028.
67
00:02:14,018 --> 00:02:15,408
And when we look at some of the pros
68
00:02:15,408 --> 00:02:17,158
and positives for becoming a state-based
69
00:02:17,158 --> 00:02:19,158
exchange, there's really quite a few.
70
00:02:19,278 --> 00:02:21,318
Not just boosting the economy for that
71
00:02:21,318 --> 00:02:23,368
given geography, within that zip code or
72
00:02:23,368 --> 00:02:25,578
county by creating jobs for folks that
73
00:02:25,578 --> 00:02:27,328
will be managing enrollment, billing,
74
00:02:27,378 --> 00:02:29,158
operations, working with issuers.
75
00:02:29,238 --> 00:02:31,418
But inherently against the headwinds
76
00:02:31,428 --> 00:02:33,828
of the ACA, and we saw this clear as
77
00:02:33,828 --> 00:02:36,978
day with the NBPP, that becoming a
78
00:02:36,978 --> 00:02:39,278
state-based exchange allows much more
79
00:02:39,278 --> 00:02:41,288
control over standardized day-to-day
80
00:02:41,288 --> 00:02:44,238
operations within the QHP ecosystem
81
00:02:44,448 --> 00:02:46,058
for the members within that state.
82
00:02:46,578 --> 00:02:47,918
So each state has a voice.
83
00:02:47,918 --> 00:02:49,358
They have a different member pool,
84
00:02:49,358 --> 00:02:51,318
with different demographics and all
85
00:02:51,318 --> 00:02:52,858
sorts of different health conditions.
86
00:02:52,973 --> 00:02:54,513
Of course, we all have to follow
87
00:02:54,523 --> 00:02:57,143
CMS' federal baseline policies like
88
00:02:57,143 --> 00:02:59,253
we talked about, those EHBs, those
89
00:02:59,253 --> 00:03:01,043
essential health benefits that everybody
90
00:03:01,149 --> 00:03:02,809
must adhere to across the country.
91
00:03:02,896 --> 00:03:05,086
But states can then look to enhance those
92
00:03:05,106 --> 00:03:07,866
benefits for members, for example, against
93
00:03:07,866 --> 00:03:09,916
the elimination of subsidy eligibility.
94
00:03:10,049 --> 00:03:12,529
States as a state-based exchange could
95
00:03:12,539 --> 00:03:14,589
utilize the additional control they have
96
00:03:14,599 --> 00:03:16,669
to create other financial opportunities
97
00:03:16,669 --> 00:03:18,116
for their members, whether it's by way
98
00:03:18,116 --> 00:03:20,206
of cost share reconciliation, whether
99
00:03:20,206 --> 00:03:21,666
it's by way of alternate funding
100
00:03:21,666 --> 00:03:23,496
methods or even alternate product type
101
00:03:23,496 --> 00:03:25,876
mandates with issuers in that state.
102
00:03:26,006 --> 00:03:27,796
So really understanding the
103
00:03:27,796 --> 00:03:29,416
capabilities that a state-based
104
00:03:29,416 --> 00:03:31,576
exchange will allow you, we recognize
105
00:03:31,576 --> 00:03:33,416
and fully understand it's a process.
106
00:03:33,426 --> 00:03:34,426
It takes a long time.
107
00:03:34,996 --> 00:03:36,606
Early adopters have definitely
108
00:03:36,606 --> 00:03:38,936
utilized and carried value from this
109
00:03:38,946 --> 00:03:41,146
process, states such as Massachusetts,
110
00:03:41,146 --> 00:03:43,256
who were pioneers even as early as
111
00:03:43,256 --> 00:03:45,116
Romneycare, leading the state-based
112
00:03:45,116 --> 00:03:47,246
exchange industry and setting those
113
00:03:47,266 --> 00:03:49,296
parameters through their RFI process.
114
00:03:49,636 --> 00:03:51,916
We do see states taking different shapes
115
00:03:51,986 --> 00:03:54,556
and forms of how they manage their
116
00:03:54,556 --> 00:03:57,046
business, not always straightforward
117
00:03:57,096 --> 00:03:58,956
for all issuers of different sizes.
118
00:03:58,956 --> 00:04:00,856
We understand larger issuers are
119
00:04:01,286 --> 00:04:02,896
more easily accommodating to those
120
00:04:02,896 --> 00:04:04,416
business processes because they
121
00:04:04,416 --> 00:04:05,996
have the resources available.
122
00:04:06,136 --> 00:04:08,656
We encourage regional issuers, provider
123
00:04:08,656 --> 00:04:11,496
issuers, or even startup issuers to
124
00:04:11,536 --> 00:04:13,276
proactively reach out, work with your
125
00:04:13,276 --> 00:04:15,306
SBEs, and understand their needs so
126
00:04:15,306 --> 00:04:16,666
you can meet them where they're at.
127
00:04:16,943 --> 00:04:18,363
So when we talk about what this
128
00:04:18,393 --> 00:04:20,213
means for issuers, we have four
129
00:04:20,213 --> 00:04:21,273
things that you need to know.
130
00:04:21,399 --> 00:04:23,629
Working with an SBE really means that your
131
00:04:23,629 --> 00:04:25,769
filing pathway will ultimately change.
132
00:04:25,819 --> 00:04:28,669
So we do know that the FFE has been
133
00:04:28,669 --> 00:04:31,209
operating on a singular submission
134
00:04:31,219 --> 00:04:33,569
timeline since the inception of the ACA.
135
00:04:34,039 --> 00:04:36,599
Converting to an SBE no longer cedes
136
00:04:36,629 --> 00:04:38,729
to the timeline that CMS has provided.
137
00:04:39,049 --> 00:04:41,039
State-based exchanges will develop
138
00:04:41,089 --> 00:04:42,969
and will implement their own deadlines
139
00:04:43,249 --> 00:04:45,409
that wrap around FFE deadlines.
140
00:04:45,729 --> 00:04:47,889
So if you operate in multiple states
141
00:04:47,999 --> 00:04:49,559
and if you're following this process for
142
00:04:49,559 --> 00:04:51,249
states during the conversion process,
143
00:04:51,549 --> 00:04:53,309
you need to have multiple implementation
144
00:04:53,309 --> 00:04:54,979
plans, multiple project plans.
145
00:04:54,979 --> 00:04:57,219
When we talk about the pathway that leads
146
00:04:57,219 --> 00:04:59,789
right into systems and requirements, what
147
00:04:59,789 --> 00:05:03,209
we see here at ClearFile from a SBE lens
148
00:05:03,739 --> 00:05:07,559
is SBEs take a byproduct of those codified
149
00:05:07,799 --> 00:05:10,169
technical materials and create their own
150
00:05:10,399 --> 00:05:12,419
state-based materials and requirements.
151
00:05:12,939 --> 00:05:15,539
And as states create these state-specific
152
00:05:15,539 --> 00:05:17,119
requirements, justification
153
00:05:17,119 --> 00:05:19,399
forms, they attempt to simplify
154
00:05:19,439 --> 00:05:21,089
these complex federal templates.
155
00:05:21,099 --> 00:05:22,119
We know the plan of benefit
156
00:05:22,119 --> 00:05:23,949
template is one of the most complex,
157
00:05:24,169 --> 00:05:26,389
labor-intensive templates, but we
158
00:05:26,389 --> 00:05:28,059
know why it drives and why it's so
159
00:05:28,059 --> 00:05:30,189
important for CMS's codification.
160
00:05:30,689 --> 00:05:32,409
So when you take a template that has
161
00:05:32,449 --> 00:05:34,739
thousands of data points, we see some
162
00:05:34,739 --> 00:05:36,309
states create their own version of a
163
00:05:36,309 --> 00:05:38,149
light plan of benefit template that
164
00:05:38,149 --> 00:05:40,169
may have a third of the components, a
165
00:05:40,169 --> 00:05:41,619
fourth of the components, or a fifth
166
00:05:41,619 --> 00:05:43,699
of the components issuers must complete
167
00:05:43,969 --> 00:05:46,276
to create more streamlined review.
168
00:05:46,736 --> 00:05:49,556
So we're also seeing states take CMS's
169
00:05:49,556 --> 00:05:52,036
lengthy review process and simplifying it.
170
00:05:52,046 --> 00:05:53,676
That's created their own efficiencies
171
00:05:53,876 --> 00:05:55,306
during the approval process.
172
00:05:55,676 --> 00:05:57,296
When we talk about the third item, when
173
00:05:57,296 --> 00:05:59,596
we talk about handoffs, and communication
174
00:05:59,616 --> 00:06:01,466
and working with states, we do find
175
00:06:01,466 --> 00:06:04,156
that SBEs are much more fluid with
176
00:06:04,166 --> 00:06:06,976
communication as we can have an open line
177
00:06:06,976 --> 00:06:08,466
and retain that open line throughout the
178
00:06:08,466 --> 00:06:10,666
filing process, pre-submission, review
179
00:06:10,676 --> 00:06:12,346
period, and ultimate certification.
180
00:06:12,906 --> 00:06:14,636
When we work with CMS, we're really
181
00:06:14,636 --> 00:06:16,586
beholden to the ticketing process.
182
00:06:16,586 --> 00:06:18,936
So we work with the CMS FEPS help desk,
183
00:06:19,166 --> 00:06:21,526
which again, that process has improved
184
00:06:21,576 --> 00:06:24,436
over time, but still yields long delay
185
00:06:24,436 --> 00:06:26,969
times, unresolved questions, unresolved
186
00:06:26,989 --> 00:06:29,189
issues for undetermined periods of time.
187
00:06:29,269 --> 00:06:30,859
The benefit for working with state-based
188
00:06:30,859 --> 00:06:32,959
exchanges is generally you have more line
189
00:06:32,959 --> 00:06:34,829
of sight to direct individuals where you
190
00:06:34,829 --> 00:06:36,859
can pick up the phone or arrange calls
191
00:06:36,859 --> 00:06:38,649
with your reviewers and with the exchange
192
00:06:38,649 --> 00:06:40,739
to answer questions quickly and timely.
193
00:06:41,237 --> 00:06:43,297
And one net new improvement that this
194
00:06:43,297 --> 00:06:45,347
would actually be favorable, and this
195
00:06:45,357 --> 00:06:47,207
is a call out for any net new issuers
196
00:06:47,237 --> 00:06:49,427
looking to enter new marketplaces.
197
00:06:49,767 --> 00:06:51,887
If you'd like an easier time
198
00:06:52,247 --> 00:06:53,857
starting off your first year,
199
00:06:53,907 --> 00:06:55,707
I'd recommend entering an SBE.
200
00:06:55,947 --> 00:06:57,317
You'll have, generally speaking,
201
00:06:57,317 --> 00:06:58,717
a more easier time during
202
00:06:58,717 --> 00:07:00,067
the network development,
203
00:07:00,107 --> 00:07:01,807
contracting, and review process.
204
00:07:01,856 --> 00:07:02,866
We know it's really hard to
205
00:07:02,876 --> 00:07:04,576
contract networks, especially
206
00:07:04,576 --> 00:07:06,106
in states with rural counties.
207
00:07:06,446 --> 00:07:08,356
So as states convert to state-based
208
00:07:08,356 --> 00:07:10,846
exchanges, encourage issuers, especially
209
00:07:10,846 --> 00:07:12,806
new market entrants to have a more
210
00:07:12,806 --> 00:07:14,676
hyper-focused view of where you'd want
211
00:07:14,676 --> 00:07:16,506
to participate in these markets and work
212
00:07:16,506 --> 00:07:18,696
with your exchange to understand how a
213
00:07:18,696 --> 00:07:20,716
compliant network will be contracted.
214
00:07:21,296 --> 00:07:22,916
We know some state-based exchanges
215
00:07:22,926 --> 00:07:24,926
have their own adequacy review
216
00:07:24,926 --> 00:07:28,196
process that could supersede CMS's
217
00:07:28,256 --> 00:07:29,586
network adequacy requirements.
218
00:07:29,596 --> 00:07:32,016
So as we're developing these validation
219
00:07:32,016 --> 00:07:33,906
tools and functions on a traditional
220
00:07:33,956 --> 00:07:36,476
FFE, we're seeing new market entrants
221
00:07:36,476 --> 00:07:39,326
fail network validations where that
222
00:07:39,326 --> 00:07:41,776
same network could be approved in
223
00:07:41,786 --> 00:07:43,816
the SBE market, allowing healthy
224
00:07:43,816 --> 00:07:45,726
competition and economies of scale
225
00:07:45,726 --> 00:07:47,686
for those members with those issuers.
226
00:07:47,828 --> 00:07:49,588
So regardless if you're a new issuer
227
00:07:49,588 --> 00:07:51,758
just starting out or a veteran issuer
228
00:07:51,758 --> 00:07:54,038
to the industry, some closing remarks
229
00:07:54,038 --> 00:07:55,818
is just we really want issuers to start
230
00:07:55,898 --> 00:07:58,178
mapping and tracking and really building
231
00:07:58,178 --> 00:07:59,738
that relationship with your states
232
00:07:59,738 --> 00:08:01,738
that you either know are converting to
233
00:08:01,808 --> 00:08:04,598
SBEs right now or that you think are
234
00:08:04,598 --> 00:08:06,458
anticipating converting to become an SBE.
235
00:08:07,025 --> 00:08:08,925
Won't be even too far-fetched to say
236
00:08:08,975 --> 00:08:11,065
as an issuer in the marketplace, even
237
00:08:11,095 --> 00:08:12,995
advocating for your states to start
238
00:08:13,075 --> 00:08:15,085
thinking about the conversion process
239
00:08:15,315 --> 00:08:17,315
could be a worthwhile conversation.
240
00:08:17,398 --> 00:08:19,008
So thank you everybody for listening in.
241
00:08:19,058 --> 00:08:20,438
Give us a like, give us a share,
242
00:08:20,578 --> 00:08:21,868
and we'll see you all next time.
00:00:00,049 --> 00:00:00,600
Hey, everybody.
2
00:00:00,630 --> 00:00:01,719
Welcome to Regulatory Joe.
3
00:00:01,839 --> 00:00:03,699
I'm Joe Boyle, president of ClearFile,
4
00:00:03,789 --> 00:00:05,119
and on today's episode, we'll be
5
00:00:05,153 --> 00:00:06,883
discussing the shift to state-based
6
00:00:06,883 --> 00:00:09,183
exchanges and why that's picking up speed.
7
00:00:09,243 --> 00:00:10,903
So before we get into the shift, we'll
8
00:00:10,903 --> 00:00:13,263
just do a quick recap on some terminology.
9
00:00:13,443 --> 00:00:15,583
What is a federally facilitated exchange?
10
00:00:15,676 --> 00:00:17,326
An FFE is where an issuer
11
00:00:17,326 --> 00:00:18,996
traditionally files through CMS,
12
00:00:19,033 --> 00:00:21,003
utilizes and relies on them for
13
00:00:21,043 --> 00:00:22,853
enrollment and marketplace functions.
14
00:00:22,943 --> 00:00:24,453
When we talk about a full state-based
15
00:00:24,453 --> 00:00:26,133
marketplace, that's where a state
16
00:00:26,173 --> 00:00:28,573
exchange manages all operations within
17
00:00:28,573 --> 00:00:30,463
the marketplace, including enrollment
18
00:00:30,463 --> 00:00:32,003
and billing on behalf of that issuer.
19
00:00:32,405 --> 00:00:34,315
A state-based exchange operating
20
00:00:34,315 --> 00:00:36,215
on a federal platform, otherwise
21
00:00:36,215 --> 00:00:39,450
known as an SBE-FP, is a traditional
22
00:00:39,450 --> 00:00:41,590
one-year transitionary period that
23
00:00:41,600 --> 00:00:43,670
allows state-based exchanges to become
24
00:00:43,670 --> 00:00:45,960
prepared with readiness, staffing,
25
00:00:46,000 --> 00:00:48,630
operations to then be able to handle
26
00:00:48,630 --> 00:00:50,540
the volumes of enrollment, the volumes
27
00:00:50,540 --> 00:00:52,170
of billing, the volumes of functions
28
00:00:52,170 --> 00:00:54,120
that members will create during the
29
00:00:54,130 --> 00:00:56,340
influx of enrollment after an issuer
30
00:00:56,350 --> 00:00:58,090
has completed the filing process.
31
00:00:58,319 --> 00:01:00,699
So if you put the ACA on a timeline from
32
00:01:00,699 --> 00:01:02,949
the inception of QHPs, there was really
33
00:01:02,949 --> 00:01:06,149
14 states that embraced the ability to
34
00:01:06,219 --> 00:01:07,989
either transition by way of a state-based
35
00:01:07,989 --> 00:01:10,419
marketplace or state-based exchange
36
00:01:10,479 --> 00:01:12,359
or become a full state-based exchange.
37
00:01:12,669 --> 00:01:14,079
When we fast-forward the clock
38
00:01:14,079 --> 00:01:15,689
to today in current time, those
39
00:01:15,699 --> 00:01:17,609
statistics have grown immensely.
40
00:01:17,659 --> 00:01:19,199
And when we fast-forward the clock to
41
00:01:19,199 --> 00:01:21,569
today for the most recent states looking
42
00:01:21,569 --> 00:01:23,069
to convert to become a state-based
43
00:01:23,069 --> 00:01:26,099
exchange for plan year 2027, Oregon
44
00:01:26,129 --> 00:01:27,939
is bringing the total industry pool
45
00:01:27,969 --> 00:01:29,769
up to about forty-three percent of all
46
00:01:29,799 --> 00:01:32,289
jurisdictions implementing this as a
47
00:01:32,289 --> 00:01:34,499
core principle for future plan years.
48
00:01:34,739 --> 00:01:37,409
If we walk back recent pace of transition
49
00:01:37,409 --> 00:01:39,099
history, we can look at a few states
50
00:01:39,099 --> 00:01:40,879
that have also followed this trajectory
51
00:01:41,059 --> 00:01:42,399
over the past couple plan years.
52
00:01:42,472 --> 00:01:43,992
Virginia moved to become a
53
00:01:43,992 --> 00:01:45,212
state-based exchange during
54
00:01:45,212 --> 00:01:46,152
plan year twenty twenty-four
55
00:01:46,623 --> 00:01:48,553
Georgia for plan year twenty twenty-five,
56
00:01:48,743 --> 00:01:50,243
Illinois for plan year twenty twenty-six.
57
00:01:50,696 --> 00:01:52,166
Like we mentioned Oregon for Plan
58
00:01:52,166 --> 00:01:54,536
Year 2027, that really sets the tone
59
00:01:54,536 --> 00:01:56,606
for an even faster pace as we enter
60
00:01:56,606 --> 00:01:58,176
and start planning strategically
61
00:01:58,396 --> 00:02:00,916
into Plan Year '29, '30, and so on.
62
00:02:01,242 --> 00:02:03,232
And when we even walk back a timeline
63
00:02:03,232 --> 00:02:05,572
for states such as Oklahoma entering
64
00:02:05,572 --> 00:02:08,022
this SBE-FP process in plan year 2026,
65
00:02:09,312 --> 00:02:11,202
now looking for a full conversion to a
66
00:02:11,202 --> 00:02:13,752
State-based Exchange in plan year 2028.
67
00:02:14,018 --> 00:02:15,408
And when we look at some of the pros
68
00:02:15,408 --> 00:02:17,158
and positives for becoming a state-based
69
00:02:17,158 --> 00:02:19,158
exchange, there's really quite a few.
70
00:02:19,278 --> 00:02:21,318
Not just boosting the economy for that
71
00:02:21,318 --> 00:02:23,368
given geography, within that zip code or
72
00:02:23,368 --> 00:02:25,578
county by creating jobs for folks that
73
00:02:25,578 --> 00:02:27,328
will be managing enrollment, billing,
74
00:02:27,378 --> 00:02:29,158
operations, working with issuers.
75
00:02:29,238 --> 00:02:31,418
But inherently against the headwinds
76
00:02:31,428 --> 00:02:33,828
of the ACA, and we saw this clear as
77
00:02:33,828 --> 00:02:36,978
day with the NBPP, that becoming a
78
00:02:36,978 --> 00:02:39,278
state-based exchange allows much more
79
00:02:39,278 --> 00:02:41,288
control over standardized day-to-day
80
00:02:41,288 --> 00:02:44,238
operations within the QHP ecosystem
81
00:02:44,448 --> 00:02:46,058
for the members within that state.
82
00:02:46,578 --> 00:02:47,918
So each state has a voice.
83
00:02:47,918 --> 00:02:49,358
They have a different member pool,
84
00:02:49,358 --> 00:02:51,318
with different demographics and all
85
00:02:51,318 --> 00:02:52,858
sorts of different health conditions.
86
00:02:52,973 --> 00:02:54,513
Of course, we all have to follow
87
00:02:54,523 --> 00:02:57,143
CMS' federal baseline policies like
88
00:02:57,143 --> 00:02:59,253
we talked about, those EHBs, those
89
00:02:59,253 --> 00:03:01,043
essential health benefits that everybody
90
00:03:01,149 --> 00:03:02,809
must adhere to across the country.
91
00:03:02,896 --> 00:03:05,086
But states can then look to enhance those
92
00:03:05,106 --> 00:03:07,866
benefits for members, for example, against
93
00:03:07,866 --> 00:03:09,916
the elimination of subsidy eligibility.
94
00:03:10,049 --> 00:03:12,529
States as a state-based exchange could
95
00:03:12,539 --> 00:03:14,589
utilize the additional control they have
96
00:03:14,599 --> 00:03:16,669
to create other financial opportunities
97
00:03:16,669 --> 00:03:18,116
for their members, whether it's by way
98
00:03:18,116 --> 00:03:20,206
of cost share reconciliation, whether
99
00:03:20,206 --> 00:03:21,666
it's by way of alternate funding
100
00:03:21,666 --> 00:03:23,496
methods or even alternate product type
101
00:03:23,496 --> 00:03:25,876
mandates with issuers in that state.
102
00:03:26,006 --> 00:03:27,796
So really understanding the
103
00:03:27,796 --> 00:03:29,416
capabilities that a state-based
104
00:03:29,416 --> 00:03:31,576
exchange will allow you, we recognize
105
00:03:31,576 --> 00:03:33,416
and fully understand it's a process.
106
00:03:33,426 --> 00:03:34,426
It takes a long time.
107
00:03:34,996 --> 00:03:36,606
Early adopters have definitely
108
00:03:36,606 --> 00:03:38,936
utilized and carried value from this
109
00:03:38,946 --> 00:03:41,146
process, states such as Massachusetts,
110
00:03:41,146 --> 00:03:43,256
who were pioneers even as early as
111
00:03:43,256 --> 00:03:45,116
Romneycare, leading the state-based
112
00:03:45,116 --> 00:03:47,246
exchange industry and setting those
113
00:03:47,266 --> 00:03:49,296
parameters through their RFI process.
114
00:03:49,636 --> 00:03:51,916
We do see states taking different shapes
115
00:03:51,986 --> 00:03:54,556
and forms of how they manage their
116
00:03:54,556 --> 00:03:57,046
business, not always straightforward
117
00:03:57,096 --> 00:03:58,956
for all issuers of different sizes.
118
00:03:58,956 --> 00:04:00,856
We understand larger issuers are
119
00:04:01,286 --> 00:04:02,896
more easily accommodating to those
120
00:04:02,896 --> 00:04:04,416
business processes because they
121
00:04:04,416 --> 00:04:05,996
have the resources available.
122
00:04:06,136 --> 00:04:08,656
We encourage regional issuers, provider
123
00:04:08,656 --> 00:04:11,496
issuers, or even startup issuers to
124
00:04:11,536 --> 00:04:13,276
proactively reach out, work with your
125
00:04:13,276 --> 00:04:15,306
SBEs, and understand their needs so
126
00:04:15,306 --> 00:04:16,666
you can meet them where they're at.
127
00:04:16,943 --> 00:04:18,363
So when we talk about what this
128
00:04:18,393 --> 00:04:20,213
means for issuers, we have four
129
00:04:20,213 --> 00:04:21,273
things that you need to know.
130
00:04:21,399 --> 00:04:23,629
Working with an SBE really means that your
131
00:04:23,629 --> 00:04:25,769
filing pathway will ultimately change.
132
00:04:25,819 --> 00:04:28,669
So we do know that the FFE has been
133
00:04:28,669 --> 00:04:31,209
operating on a singular submission
134
00:04:31,219 --> 00:04:33,569
timeline since the inception of the ACA.
135
00:04:34,039 --> 00:04:36,599
Converting to an SBE no longer cedes
136
00:04:36,629 --> 00:04:38,729
to the timeline that CMS has provided.
137
00:04:39,049 --> 00:04:41,039
State-based exchanges will develop
138
00:04:41,089 --> 00:04:42,969
and will implement their own deadlines
139
00:04:43,249 --> 00:04:45,409
that wrap around FFE deadlines.
140
00:04:45,729 --> 00:04:47,889
So if you operate in multiple states
141
00:04:47,999 --> 00:04:49,559
and if you're following this process for
142
00:04:49,559 --> 00:04:51,249
states during the conversion process,
143
00:04:51,549 --> 00:04:53,309
you need to have multiple implementation
144
00:04:53,309 --> 00:04:54,979
plans, multiple project plans.
145
00:04:54,979 --> 00:04:57,219
When we talk about the pathway that leads
146
00:04:57,219 --> 00:04:59,789
right into systems and requirements, what
147
00:04:59,789 --> 00:05:03,209
we see here at ClearFile from a SBE lens
148
00:05:03,739 --> 00:05:07,559
is SBEs take a byproduct of those codified
149
00:05:07,799 --> 00:05:10,169
technical materials and create their own
150
00:05:10,399 --> 00:05:12,419
state-based materials and requirements.
151
00:05:12,939 --> 00:05:15,539
And as states create these state-specific
152
00:05:15,539 --> 00:05:17,119
requirements, justification
153
00:05:17,119 --> 00:05:19,399
forms, they attempt to simplify
154
00:05:19,439 --> 00:05:21,089
these complex federal templates.
155
00:05:21,099 --> 00:05:22,119
We know the plan of benefit
156
00:05:22,119 --> 00:05:23,949
template is one of the most complex,
157
00:05:24,169 --> 00:05:26,389
labor-intensive templates, but we
158
00:05:26,389 --> 00:05:28,059
know why it drives and why it's so
159
00:05:28,059 --> 00:05:30,189
important for CMS's codification.
160
00:05:30,689 --> 00:05:32,409
So when you take a template that has
161
00:05:32,449 --> 00:05:34,739
thousands of data points, we see some
162
00:05:34,739 --> 00:05:36,309
states create their own version of a
163
00:05:36,309 --> 00:05:38,149
light plan of benefit template that
164
00:05:38,149 --> 00:05:40,169
may have a third of the components, a
165
00:05:40,169 --> 00:05:41,619
fourth of the components, or a fifth
166
00:05:41,619 --> 00:05:43,699
of the components issuers must complete
167
00:05:43,969 --> 00:05:46,276
to create more streamlined review.
168
00:05:46,736 --> 00:05:49,556
So we're also seeing states take CMS's
169
00:05:49,556 --> 00:05:52,036
lengthy review process and simplifying it.
170
00:05:52,046 --> 00:05:53,676
That's created their own efficiencies
171
00:05:53,876 --> 00:05:55,306
during the approval process.
172
00:05:55,676 --> 00:05:57,296
When we talk about the third item, when
173
00:05:57,296 --> 00:05:59,596
we talk about handoffs, and communication
174
00:05:59,616 --> 00:06:01,466
and working with states, we do find
175
00:06:01,466 --> 00:06:04,156
that SBEs are much more fluid with
176
00:06:04,166 --> 00:06:06,976
communication as we can have an open line
177
00:06:06,976 --> 00:06:08,466
and retain that open line throughout the
178
00:06:08,466 --> 00:06:10,666
filing process, pre-submission, review
179
00:06:10,676 --> 00:06:12,346
period, and ultimate certification.
180
00:06:12,906 --> 00:06:14,636
When we work with CMS, we're really
181
00:06:14,636 --> 00:06:16,586
beholden to the ticketing process.
182
00:06:16,586 --> 00:06:18,936
So we work with the CMS FEPS help desk,
183
00:06:19,166 --> 00:06:21,526
which again, that process has improved
184
00:06:21,576 --> 00:06:24,436
over time, but still yields long delay
185
00:06:24,436 --> 00:06:26,969
times, unresolved questions, unresolved
186
00:06:26,989 --> 00:06:29,189
issues for undetermined periods of time.
187
00:06:29,269 --> 00:06:30,859
The benefit for working with state-based
188
00:06:30,859 --> 00:06:32,959
exchanges is generally you have more line
189
00:06:32,959 --> 00:06:34,829
of sight to direct individuals where you
190
00:06:34,829 --> 00:06:36,859
can pick up the phone or arrange calls
191
00:06:36,859 --> 00:06:38,649
with your reviewers and with the exchange
192
00:06:38,649 --> 00:06:40,739
to answer questions quickly and timely.
193
00:06:41,237 --> 00:06:43,297
And one net new improvement that this
194
00:06:43,297 --> 00:06:45,347
would actually be favorable, and this
195
00:06:45,357 --> 00:06:47,207
is a call out for any net new issuers
196
00:06:47,237 --> 00:06:49,427
looking to enter new marketplaces.
197
00:06:49,767 --> 00:06:51,887
If you'd like an easier time
198
00:06:52,247 --> 00:06:53,857
starting off your first year,
199
00:06:53,907 --> 00:06:55,707
I'd recommend entering an SBE.
200
00:06:55,947 --> 00:06:57,317
You'll have, generally speaking,
201
00:06:57,317 --> 00:06:58,717
a more easier time during
202
00:06:58,717 --> 00:07:00,067
the network development,
203
00:07:00,107 --> 00:07:01,807
contracting, and review process.
204
00:07:01,856 --> 00:07:02,866
We know it's really hard to
205
00:07:02,876 --> 00:07:04,576
contract networks, especially
206
00:07:04,576 --> 00:07:06,106
in states with rural counties.
207
00:07:06,446 --> 00:07:08,356
So as states convert to state-based
208
00:07:08,356 --> 00:07:10,846
exchanges, encourage issuers, especially
209
00:07:10,846 --> 00:07:12,806
new market entrants to have a more
210
00:07:12,806 --> 00:07:14,676
hyper-focused view of where you'd want
211
00:07:14,676 --> 00:07:16,506
to participate in these markets and work
212
00:07:16,506 --> 00:07:18,696
with your exchange to understand how a
213
00:07:18,696 --> 00:07:20,716
compliant network will be contracted.
214
00:07:21,296 --> 00:07:22,916
We know some state-based exchanges
215
00:07:22,926 --> 00:07:24,926
have their own adequacy review
216
00:07:24,926 --> 00:07:28,196
process that could supersede CMS's
217
00:07:28,256 --> 00:07:29,586
network adequacy requirements.
218
00:07:29,596 --> 00:07:32,016
So as we're developing these validation
219
00:07:32,016 --> 00:07:33,906
tools and functions on a traditional
220
00:07:33,956 --> 00:07:36,476
FFE, we're seeing new market entrants
221
00:07:36,476 --> 00:07:39,326
fail network validations where that
222
00:07:39,326 --> 00:07:41,776
same network could be approved in
223
00:07:41,786 --> 00:07:43,816
the SBE market, allowing healthy
224
00:07:43,816 --> 00:07:45,726
competition and economies of scale
225
00:07:45,726 --> 00:07:47,686
for those members with those issuers.
226
00:07:47,828 --> 00:07:49,588
So regardless if you're a new issuer
227
00:07:49,588 --> 00:07:51,758
just starting out or a veteran issuer
228
00:07:51,758 --> 00:07:54,038
to the industry, some closing remarks
229
00:07:54,038 --> 00:07:55,818
is just we really want issuers to start
230
00:07:55,898 --> 00:07:58,178
mapping and tracking and really building
231
00:07:58,178 --> 00:07:59,738
that relationship with your states
232
00:07:59,738 --> 00:08:01,738
that you either know are converting to
233
00:08:01,808 --> 00:08:04,598
SBEs right now or that you think are
234
00:08:04,598 --> 00:08:06,458
anticipating converting to become an SBE.
235
00:08:07,025 --> 00:08:08,925
Won't be even too far-fetched to say
236
00:08:08,975 --> 00:08:11,065
as an issuer in the marketplace, even
237
00:08:11,095 --> 00:08:12,995
advocating for your states to start
238
00:08:13,075 --> 00:08:15,085
thinking about the conversion process
239
00:08:15,315 --> 00:08:17,315
could be a worthwhile conversation.
240
00:08:17,398 --> 00:08:19,008
So thank you everybody for listening in.
241
00:08:19,058 --> 00:08:20,438
Give us a like, give us a share,
242
00:08:20,578 --> 00:08:21,868
and we'll see you all next time.
