Table of Contents: Designing a Marketplace

Marketplace Structure

• MS 1 Marketplace type
• MS 2 Marketplace name
• MS 3 Marketplace website
• MS 4 What is the Marketplace governance model?
  a. New or existing government agency
  b. Quasi-governmental agency
  c. Non-profit organization
• MS 5 What is the Marketplace’s standards for industries/entities with a conflict of interest (e.g. issuers, brokers, providers) serving on the Governing Board (if one exists)?
  a. Prohibits
  b. Permits
  c. Requires
  d. Other
• MS 6 What is the projected annual budget amount for ongoing Marketplace operations?
• MS 7 What revenue/financing model(s) will the Marketplace use to fund its operations on an ongoing basis?

Eligibility and Enrollment

• EE 1 What are the Marketplace’s outreach and education plans?
• EE 2 How is the Marketplace structuring its call center?
• EE 3 Does the Marketplace offer a live chat feature?
• EE 4 Does the Marketplace allow applicants to browse plans before applying?
• EE 5 Is the Marketplace website available in languages other than English?
• EE 6 How has the state organized the Marketplace and Medicaid eligibility IT systems?
  a. A new single IT system for both programs
  b. Two new separate IT systems, one for each program
  c. A new IT system for the Marketplace, existing system for Medicaid
• EE 7 How is the Marketplace involved in eligibility determinations for Medicaid?
  a. The Marketplace makes final eligibility determinations for Medicaid
  b. The Marketplace conducts an initial assessment, then electronically transfers applicant information to Medicaid
  c. The Marketplace conducts an initial assessment, then transfers applicant information to Medicaid using non-electronic means
  d. The Marketplace does not play a role in Medicaid eligibility determinations
  e. Other
• EE 8 Which standardized application form did the Marketplace adopt?
  a. Single streamlined application form developed by HHS
  b. State-developed alternative form
• EE 9 What programs are included in the Marketplace application form?
  a. QHP/APTC/CSR and MAGI Medicaid/CHIP
  b. QHP/APTC/CSR, MAGI Medicaid/CHIP, and non-MAGI Medicaid
  c. QHP/APTC/CSR, MAGI Medicaid/CHIP, non-MAGI Medicaid, and other public benefit programs (e.g. TANF, SNAP, etc.)
• EE 10 Does the Marketplace allow applicants to adjust the amount or percentage of the Advanced Premium Tax Credit (APTC) they use? If so, how does that occur?
• EE 11 Does the Marketplace allow consumers to search, filter, or sort plan options by any of the following plan features?
  a. Metal tier
  b. Premium
  c. Deductible
  d. Out-of-pocket maximum
  e. Cost-sharing
  f. Provider
  g. Insurance company
  h. Quality rating
  i. Other
• EE 12 How does the Marketplace manage premium billing and collection for individuals?
  a. Only issuers bill and collect premiums
  b. Both issuers and the Marketplace bill and collect premiums; consumers may choose
  c. Marketplace bills and collects first month’s premium, issuers bill and collect subsequent premiums
  d. Other
• EE 13 What methods of payment are offered to Individual Marketplace enrollees?
  a. Check
  b. Cash
  c. Automated Clearing House (ACH)
  d. Electronic Fund Transfer (EFT)
  e. Money order
  f. Credit card
  g. Debit card
  h. General purpose prepaid debit card
  i. Other
• EE 14 What is the grace period for QHP enrollees not receiving APTC?
• EE 15 Is there a nominal premium underpayment amount that is permitted by the Marketplace?

Consumer Assistance

• CA 1 How does the Marketplace organize its in-person consumer assistance?
  a. Navigators only
  b. In-Person Assisters (IPAs) only
  c. Navigator and In-Person Assister (IPA) programs that are separate and distinct in function or focus
  d. Navigator and In-Person Assister (IPA) programs that are functionally the same (distinct only in funding source)
• CA 2 How much total funding has the Marketplace granted to in-person consumer assistance entities (Navigators and IPAs) for 2013/2014?
• CA 3 How has the Marketplace funded the Navigator program?
• CA 4 What term does the Marketplace use for Navigators/Navigator entities?
• CA 5 What are the Marketplace's requirements for Navigator eligibility, certification, or licensure?
• CA 6 Which entity oversees Navigator certification or licensure?
  a. Marketplace
  b. Department of Insurance
  c. Other
• CA 7 Which entity oversees Navigator training?
  a. Marketplace
  b. Department of Insurance
  c. Other
• CA 8 How many training hours/days are required for Navigators?
• CA 9 How is the Navigator training offered?
  a. Online
  b. In person
  c. Other
• CA 10 Is the training available to non-Navigator entities? If so, for whom and what parts of the training?
• CA 11 Do Navigators provide assistance to small businesses and employees in the SHOP?
• CA 12 Do Navigators have designated access to the online application portal to manage clients?
• CA 13 How does the Marketplace display information regarding Navigator availability?
• CA 14 How does the Marketplace structure payments to Navigator grantees?
  a. Fixed grant amount
  b. Performance or volume-based grant
  c. Hybrid of both payment structures
  d. Other
• CA 15 Which entities have been awarded Navigator grants?
• CA 16 What term does the Marketplace use for IPAs/IPA entities?
• CA 17 What are the Marketplace's requirements for IPA eligibility, certification, or licensure?
• CA 18 Which entity oversees IPA certification or licensure?
  a. Marketplace
  b. Department of Insurance
  c. Other
• CA 19 Which entity oversees IPA training?
  a. Marketplace
  b. Department of Insurance
  c. Other
• CA 20 How many training hours/days are required for IPAs?
• CA 21 How is the IPA training offered?
  a. Online
  b. In person
  c. Other
• CA 22 Is the training available to non-IPA entities? If so, for whom and what parts of the training?
• CA 23 Do IPAs provide assistance to small businesses and employees in the SHOP?
• CA 24 Do IPAs have designated access to the online application portal to manage clients?
• CA 25 How does the Marketplace display information regarding IPA availability?
• CA 26 How does the Marketplace structure payments to IPA grantees?
  a. Fixed grant amount
  b. Performance or volume-based grant
  c. Hybrid of both payment structures
  d. Other
• CA 27 Which entities have been awarded IPA grants?
• CA 28 Will the Marketplace have Certified Application Counselors (CACs)?
• CA 29 Which entity oversees CAC training?
  a. Marketplace
  b. Department of Insurance
  c. Other
• CA 30 How many training hours/days are required for CACs?
• CA 31 How is the CAC training offered?
  a. Online
  b. In person
  c. Other
• CA 32 Do CACs provide assistance to small businesses and employees in the SHOP?
• CA 33 How will the Marketplace evaluate the performance and effectiveness of consumer assistance programs (Navigators, In-Person Assistors, Certified Application Counselors etc.)?

Brokers

• BR 1 What roles can brokers play in assisting consumers seeking coverage through the Marketplace?
  a. Assist individuals in selecting and enrolling in a QHP
  b. Assist individuals in applying for advance premium tax credits (APTC) and cost sharing reductions (CSRs)
  c. Assist employers in applying for and selecting plans in the SHOP
  d. No role in the Marketplace
• BR 2 Which entity oversees broker training?
  a. Marketplace
  b. Department of Insurance
  c. Other
• BR 3 How many training hours are required for brokers?
• BR 4 How is the broker training offered?
  a. Online
  b. In person
  c. Other
• BR 5 What does the Marketplace require of brokers selling QHPs?
  a. Brokers must display and facilitate enrollment in all Marketplace QHPs from all issuers (regardless of appointments/relationships with issuers in the market outside the Marketplace)
  b. Brokers may elect to only sell QHPs offered by issuers with whom the broker has an appointment in the market outside the Marketplace
  c. Other
• BR 6 From which entity(ies) do brokers receive payment for broker commissions?
  a. QHP issuers directly
  b. QHP issuers via the Marketplace
  c. Other
• BR 7 What standards, if any, has the Marketplace set for broker compensation levels?
  a. Fees must mirror what issuers pay brokers for enrollment into similar plans offered outside the Marketplace
  b. Fees are set by the issuers or issuer-broker negotiations subject to Marketplace requirements or approval
  c. Fees will be set based on a fee schedule established by the Marketplace
  d. No Marketplace policy or oversight of broker fees
  e. Other
• BR 8 Do brokers have designated access to the online application portal to manage clients?
• BR 9 Does the Marketplace display information regarding broker availability?
• BR 10 Will the state permit web-based brokers to sell Marketplace QHPs?
• BR 11 What additional requirements, if any, will be set for web-based brokers?

Plan Management

• PM 1 What process does the Marketplace use to certify QHPs?
  a. Selective contractor/active purchaser (competitive procurement)
  b. Market organizer (standardized plans or limits on number of plans offered)
  c. Enhanced certification (including state-developed standards in addition to the federal minimum)
  d. Basic certification (ensuring minimum Federal Standards)
• PM 2 Which entities are involved in reviewing and certifying QHP submissions?
  a. Department of Insurance
  b. Marketplace
  c. Department of Health
  d. Other
• PM 3 For how long does QHP certification last?
• PM 4 Does Marketplace apply any participation bans for issuers in the state not participating in 2014?
• PM 5 Does the Marketplace require issuers seeking QHP certification to offer plans in both the Individual Marketplace and SHOP?
• PM 6 In what parts of the state are issuers required to offer QHPs?
  a. Statewide
  b. In any county/rating area in which the issuer offers plans outside of the Marketplace
  c. In any county/rating area the issuer chooses
  d. Other
• PM 7 In what metal tiers (in addition to the requisite Gold and Silver tiers) does the Marketplace require issuers to sell QHPs?
  a. Platinum
  b. Bronze
  c. Catastrophic
  d. none
• PM 8 Are there any requirements for issuers to participate in the Marketplace or that limit the sale of certain types of plans solely through the Marketplace?
• PM 9 Does the Marketplace require a standardized plan design? If so, for which tiers?
• PM 10 Does the Marketplace require a standardized plan design for CSR Silver plans?
• PM 11 What is the Marketplace's limit, if any, on the number of plans that an issuer can offer at each metal level?
• PM 12 Is there a meaningful difference standard for QHPs sold on the Marketplace? If so, what is the standard?
• PM 13 What are the Marketplace's network adequacy standards for QHPs?
• PM 14 What are the Marketplace's Essential Community Provider (ECP) standards for QHPs?
• PM 15 What are the Marketplace's plans for measuring and reporting QHP quality data standards? In what year will quality data begin to be displayed?
• PM 16 How many geographic rating areas are in the state?
• PM 17 What Essential Health Benefits (EHB) standards, if any, will the state apply regarding substitution of benefits/benefit design flexibility?
  a. Prohibited
  b. Permitted for certain benefit categories, services, or plans
  c. Permitted
  d. Other
• PM 18 What is the state's maximum allowable tobacco rating factor?
  a. 1.5:1
  b. Prohibited (1:1)
  c. Other
• PM 19 What is the state's age rating standard?
  a. 3:1
  b. Prohibited (1:1)
  c. Other
• PM 20 Has the state merged the individual and small group market risk pools?
• PM 21 What standards (in addition to minimum ACA requirements), if any, is the state applying to plans sold outside the Marketplace?
• PM 22 Are QHP issuers required to sell all QHPs in the market outside the Marketplace as well?
• PM 23 What types of pediatric dental coverage is offered in the Marketplace?
  a. Stand-alone dental plans (SADP)
  b. Bundled medical and dental plans
  c. Embedded medical and dental plan
  d. Other
• PM 24 If a qualified individual purchases a QHP lacking pediatric dental coverage, will there be a requirement to purchase a stand-alone dental plan?
  a. No
  b. Yes, for families with children
  c. Yes, for all consumers
  d. Other
• PM 25 Will the state administer risk adjustment in 2014 or in future years?
• PM 26 Will the state administer the reinsurance program in 2014 or in future years?
• PM 27 Is the state planning to implement the Basic Health Plan in 2015?
• PM 28 Is the state providing additional state-funded premium and/or cost-sharing subsidies? If so, for which enrollees?

Plan Offerings

• PO 1 How many issuers are offering QHPs in the Individual Marketplace?
• PO 2 How many QHPs are being offered in the Individual Marketplace market?
• PO 3 How many issuers are offering QHPs in the SHOP?
• PO 4 How many QHPs are being offered in the SHOP?
• PO 5 How many Multi-state Plans (MSPs) are offered in the Marketplace?
• PO 6 How many Medicaid MCOs are offering QHPs in the Marketplace?
• PO 7 How many QHPs being offered in the Individual Marketplace have pediatric dental as an embedded benefit?
• PO 8 How many issuers are offering Stand Alone Dental Plans (SADPs) in the Individual Marketplace?
• PO 9 How many Stand Alone Dental Plans (SADPs) are being offered in the Individual Marketplace?

SHOP

• SH 1 How is the SHOP managed and administered?
  a. By the Marketplace
  b. Outsourced to a vendor
  c. Other
• SH 2 What employee choice options does the SHOP offer qualified employers?
  a. Single QHP
  b. One tier, multiple issuers
  c. One issuer, multiple tiers
  d. Multiple tiers, multiple issuers
  e. All tiers, all issuers
• SH 3 What options does the SHOP offer for employers to set the employer premium contribution level?
  a. Defined employer contribution amount
  b. Defined employee contribution amount
  c. Defined employer percentage
  d. Employer reference plan (ERP) indexing
  e. Other
• SH 4 What is the minimum participation rate for qualified employers in the SHOP?
• SH 5 What is the minimum employer contribution requirement for qualified employers in the SHOP?
• SH 6 What is the grace period for qualified employers in the SHOP?
• SH 7 What is the effective date of termination of SHOP coverage after the grace period has expired?
• SH 8 Will the SHOP allow groups to be reinstated if they make full payment after the grace period has expired? If so, what is the time frame by which this payment must be made?
• SH 9 How frequently may issuers change rates for SHOP QHPs?
  a. Quarterly
  b. Annually
  c. Other