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Maryland Health Exchange Profile


Establishing the Exchange

On April 12, 2011, Governor Martin O’Malley (D) signed SB 182/HB 166 into law establishing the Maryland Health Benefit Exchange (MBHE). In May of the following year, Governor O’Malley signed additional exchange legislation (SB 372/HB 433) which addressed multiple exchange implementation and operational issues and was based on recommendations by the Exchange’s Board of Directors and advisory groups from 2011. In August 2012, the state announced that the name for the new insurance marketplace would be Maryland Health Connection.

Structure: The legislation defines the MBHE as a quasi-governmental organization, specifically a “public corporation and independent unit of state government.”

Governance: The MBHE is governed by a nine-member board, including the Executive Director of Maryland’s Health Care Commission as the Chair, Secretary of Health and Mental Hygiene, Commissioner of Insurance, and six members appointed by the Governor and with consent from the Senate. Half of these members represent employers and individuals using the Maryland Health Connection and half provide specific knowledge and expertise. Board members cannot be affiliated with a carrier, insurance producer, third-party administrator, managed care organization, person contracting or in position to contract with the exchange, or any trade associations for these entities.

Current appointed Board members are:

  • Darrell Gaskin (Vice Chair), Johns Hopkins Bloomberg School of Public Health
  • Kenneth Apfel, University of Maryland, School of Public Policy
  • Georges Benjamin, American Public Health Association
  • Jennifer Goldberg, Maryland Legal Aid Bureau
  • Enrique Martinez-Vidal, AcademyHealth and Robert Wood Johnson Foundation
  • Thomas Saquella, Maryland Retailers Association

The Board hired an Executive Director in mid-September in 2011.

The MBHE is required by statute to maintain at least two standing advisory committees, though the subjects may change to support the decision-making for that particular year. Currently, the Board has established four advisory committees to study particular topics: the Navigator program, continuity of care, plan management, and finance and sustainability. Staff from the MBHE and other state agencies will look to the Advisory Committees to make recommendations on policy options, not to vote on policy decisions.

The MBHE also formed an Exchange Implementation Advisory Committee to provide technical and operational advice to MBHE staff and the Board. The Implementation Advisory Committee includes senior information technology (IT) and operations executives from organizations that intend to participate as insurance carriers or service providers in the individual or small business exchange. In addition, a number of spots on the Advisory Committee were reserved for stakeholders from community advocacy groups, academic organizations, and general technology advisors.

The Board has also concluded there should be a steering committee to examine risk adjustment, reinsurance, and risk corridors. This steering committee includes members from the Governor’s Office of Health Care Reform, the Maryland Health Insurance Plan, the MBHE, the Insurance Administration, Medicaid, the Health Services Cost Review Commission, and the Maryland Health Care Commission.

Contracting with Plans: In the first two years of operation, Maryland Health Connection will act as a clearinghouse with any qualified health plan (QHP) in the state eligible to participate. Beginning in 2016, Maryland Health Connection will have the authority to employ an alternative contracting option or active purchaser strategy, such as competitive bidding or negotiations with carriers.

QHPs participating in Maryland Health Connection must offer at least one plan at the silver level and one at the gold level outside the Exchange. Each insurance carrier will offer no more than four benefit designs per metal level, though separate limits apply for the individual and Small Business Health Options Plan (SHOP) exchanges. In addition, carriers with state market share above a certain threshold must sell a QHP in Maryland Health Connection. The minimum participation threshold for carriers will be $20 million in the small group market and $10 million in the individual market. Despite exceptions for small carriers, those offering a catastrophic plan outside Maryland Health Connection will be required to offer at least one catastrophic plan in the Health Connection, regardless of market share.

The MBHE board approved plan certification policies related to: service area designation; licensure and solvency; benefit design standards and review; marketing standards; review of rate changes; transparency and quality data; and access to essential community providers. The Exchange will perform annual reviews of all participating carriers and provide performance reviews that highlight areas for improvement. Carriers will be required to complete corrective action plans based on the issues in the annual review, and recertification will occur biannually.

In the first year, insurers will “self-define” network adequacy standards and submit provider data to the CRISP (Chesapeake Regional Information System for our Patients) Provider Information Management System. Insurance carriers will be required to participate in the Maryland Health Care Commission’s existing quality and performance evaluation system. In addition, carriers will be required to provide the MBHE with data each quarter regarding the number and type of providers available, the ability of enrollees to access services, and utilization and complaint data. The MBHE will accept Medicaid or Commercial accreditation and allow a one year grace period for non-accredited insurers to become accredited. In the second year of operation, the MBHE will reassess accreditation requirements, appropriate standardized network adequacy requirements, and other possible changes to plan management policies.

Dental and Vision Plans:
 In December 2012, the Board revised the interim plan management policies and procedures for adult and pediatric dental and vision plans. The MBHE anticipates requiring that all adult vision and dental coverage be offered through stand-alone plans with price disclosure to allow consumers to compare options. Pediatric vision coverage cannot be offered through stand-alone plans and must always be offered as part of the health benefit plan or as an additional benefit that can be purchased along with the health benefit plan. Pediatric dental coverage can be offered as part of the health benefit plan, as an additional benefit that can be purchased separately, or through a stand-alone plan.

Risk Adjustment, Reinsurance, and Risk Corridors: Maryland intends to use federal services to administer the state’s risk adjustment program but the MBHE will administer the state’s reinsurance program.

Consumer Assistance and Outreach: The online portal for Maryland Health Connection, with the new branding strategy, went live in August 2012. The MBHE plans to focus on outreach and training in the first half of 2013.

The Consolidated Service Center will be the main entry point for questions related to Maryland Health Connection, Medicaid eligibility and enrollment, and any other question related to health insurance. The Center will be prepared to manage calls from individuals, employees, employers, Navigators, Assisters, and others. To implement the Center, MBHE is working closely with multiple other state agencies to determine how best to address consumer questions on a variety of topics. In addition, the MBHE plans to contract with two vendors to project call volume, run cost and pricing impacts, and to provide project management support throughout implementation. The call center is expected to be operational beginning in June 2013.

Based on subcontractor analyses and stakeholder feedback, the MBHE will establish a regional Navigator strategy that is similar to the approach used by other state programs. The MBHE will contract with one Outreach Entity in each of six regions, though Outreach Entities can be either a single entity or a partnership of entitles in which one organization serves as the prime. In addition to certified individual Navigators, the Outreach Entities can also use non-certified personnel or “assisters” to provide certain services such as consumer education and outreach, facilitating eligibility determinations and redeterminations for premium tax subsidies or public coverage, and facilitating applications processes.

The Outreach Entities will have a dedicated Exchange Navigator Program Manager to provide grant management, monitor performance, and manage databases of individual Navigator certification and training. The MBHE will supplement the Outreach Entities with statewide services that target a small percentage of the population in any given area but are needed statewide (e.g., services for the hearing and vision impaired). The MBHE will also provide the web portal and marketing materials to enable the Navigators to help consumers, access to dedicated customer service representatives at the call center, and a comprehensive training program to certify/license navigators. The Outreach Entities are also required to establish relationships with Local Health Departments. The Maryland Insurance Administration has regulatory oversight over the Outreach Entities.

There will be separate Navigator programs for the small group and individual markets. The SHOP Navigators will be required to obtain a special license from the Insurance Commissioner and training/authorization from the MBHE. Outreach Entities are encouraged, but not required, to provide SHOP exchange Navigator services through direct employment or engagement with SHOP Navigators. Staff can be trained to serve as Navigators to both the individual and SHOP exchanges, but the funding for the two exchanges will be tracked separately. The MBHE also plans to employ SHOP exchange Navigators that will be located in the call center and will perform limited outreach functions.

The Grant Solicitation for Outreach Entities was released in late 2012. Applications are due in late January and the grant awardees will be announced in April. Navigator training will begin in the summer of 2013.The first grant period for Outreach Entities is anticipated to be April 2013 through June 2014, with approximately $4 million available in grant funding.

Insurance Producers can sell plans both inside and outside Maryland Health Connection, after receiving training and authorization by the Health Connection, and will be paid directly by carriers. MBHE will require carriers to retain information about policies and procedures used to determine producer compensation both inside and outside the Connection. The Maryland Insurance Administration and the MBHE will use this information to assess whether additional action is necessary beginning in the second year of operations.

Small Business Health Options Program (SHOP) Exchange: In 2014 and 2015, the size of small employers in the SHOP Exchange will be limited to an average of 50 or fewer employees. In addition, the insurance market for SHOP exchange will not be merged with the market for individuals. Both traditional employer choice plans and the defined contribution option will be available within the SHOP exchange.

The MBHE issued recommendations, including that for the employee choice option at least 75% of employees from a group must enroll in SHOP QHPs. In addition, the employee choice model should use an individual rating methodology to address concerns about adverse selection, while an average age rating methodology should be used for the employer choice model.

Currently, third party administrators and brokers play a key role in the selection, purchase, and administration of insurance for small businesses. For this reason, the MHBE is planning to certify entities to service the small group market on behalf of the Health Connection if they meet the criteria of the ACA and state requirements, adhere to a rigorous set of performance measure and service levels, and be subject to oversight by the MHBE. These certified entities will receive compensation on a per-employee-per-month basis commensurate with what the market pays for services today, currently estimated at 0.5% to 1.0% of premiums.

Financing: Once Maryland Health Connection is operational, it is authorized to collect fees or assessments from participating plans, though not to the extent that the fees create a competitive disadvantage with plans offered outside the Health Connection. A joint executive-legislative committee is considering a range of additional financing options. At the same time, an Advisory Committee focused on exchange financing strategies continues to meet regularly.

In September, a subcontractor providing analytic support to the Joint Committee recommended a financing model that blends multiple approaches rather than relying on a single revenue source. An example hybrid financing approach might include a combination of revenue collected from the non-group, small group, and large group markets, providers, and cigarette sales. In December 2012, the Joint Committee submitted a report to the Governor and General Assembly which included the following recommendations: the state should use a combination of at least two revenue streams; a transaction-based assessment on the whole non-group and small group market is preferable to an assessment applied only to plans inside Maryland Health Connection; and a broad-based assessment on the larger group market and/or an increase in the tobacco tax should be considered, while an assessment on hospitals should not be considered.

Information Technology (IT): Maryland intends to create a common IT system for Maryland Health Connection, Medicaid, and the Maryland Children’s Health Insurance Program (CHIP). In order to submit an application for the Early Innovator grant in 2010, Maryland initially focused development of the Health Connection’s IT systems on a prototype for pre-screening for eligibility and information verification. In 2011, the Board solicited subcontractor assistance with Phase 1A of the IT development program, which provides the core functionality for the individual exchange and Modified Adjusted Gross Income (MAGI) Medicaid eligibility determinations. Phase 1B focuses on SHOP technology enablement options and operations implementation, Phase 2 on non-MAGI determinations, and Phase 3 on other social service programs such as the Supplemental Nutrition Assistance Program (SNAP) and the Temporary Assistance for Needy Families (TANF). In the end, Maryland Health Connection’s IT system will be a single point of entry and will integrate with other state IT systems, such as the Medicaid Management Information System (MMIS), the Issuer Management System (SERFF), and the Client Automated Resource and Eligibility System (CARES) for non-MAGI eligibility determination and other social programs. To assist in financing the information technology upgrades of the state’s Medicaid eligibility systems, Maryland applied for and received CMS approval of an Advanced Planning Document for enhanced federal funding.

Maryland completed an IT gap analysis and held a series of formal Joint Application Development (JAD) sessions. The JAD sessions provided an opportunity for key stakeholders to discuss IT issues related to: eligibility and enrollment; plan management; billing and payment; customer support; and reporting, transparency, and notifications. JAD participants include representatives from the Department of Health and Mental Hygiene (DHMH), the Department of Human Resources (DHR), as well as experts from insurance carriers, third-party administrators, Co-Ops, and managed care organizations. The state agencies involved in the JAD sessions also participate in the Exchange IT Systems Leadership Team, along with the Department of Information Technology, Medicaid, and the state’s Chief Innovation Officer. The leadership team meets weekly to provide guidance as the state plans and implements the IT system. Maryland is also participating in theEnroll UX 2014 project, which is a public-private partnership creating design standards for exchanges that all states can use.

The output from the JAD sessions was used to develop a strategy focused on replacing legacy enrollment and eligibly systems with commercial off-the-shelf (COTS) products. Maryland awarded a contract for assistance with combining COTS products and released another RFP in June 2012 for independent verification and validation during the design and development of Phases 1A and 1B. Maryland completed development and testing of all system components required for CMS certification by the end of 2012, with additional testing to be conducted in early 2013. Also in 2012, Maryland began Phase 1B and completed the Third Party Administrator (TPA) SHOP Certification Program, which defines the integration parameters and data elements required to interface the SHOP exchange with the TPA Marketplace and Back Office Administrative Systems. Maryland has also completed the initial design of the single sign-on and identity management strategy, which included discussions with the DMHR and DHR security officers.

The MBHE has decided to collect the initial billing for enrollment in the individual exchange, but will not perform ongoing billing and collections. This strategy clearly establishes the timing of the coverage effective date, relieves Maryland Health Connection of managing partial payments and arrears management, and takes advantage of mature capabilities of carriers for billing and collections. As a result, Maryland Health Connection will have additional points of carrier integrations, including: transmitting payment preference information to the carriers; automated data exchange for ongoing payment collections, eligibility changes, and changes in the advanced premium tax credit; and call transfers between carriers and the Health Connection’s customer service representatives.

Basic Health Program (BHP): Maryland is considering establishing an optional coverage program available through the Affordable Care Act (ACA) which allows states to use federal funding to offer subsidized health insurance to adults with incomes between 139 and 200% of the federal poverty level (FPL) who would otherwise be eligible to purchase subsidized coverage through an Exchange. The DHMH, together with a subcontractor, completed an analysis of the effect of a BHP in Maryland and found that it may redirect funds away from Maryland Health Connection. In addition, the state would have to bear expenses related to program administration and quality monitoring. In February 2012, the MBHE Board agreed with the Department’s recommendation that a decision on the BHP be deferred pending availability of additional federal guidance and information about rates and fiscal risks to the state.

Essential Health Benefits (EHB): The Affordable Care Act requires that all individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. The Maryland Health Care Reform Coordinating Council formed an advisory committee to assist in selecting the state’s EHB benchmark plan. On December 17, 2012, the Council reevaluated the possible benchmark plans in light of new federal guidance and selected the state’s largest small group plan, CareFirst of Maryland (Blue Cross Blue Shield)-HMO HSA Open Access plan. The Council also designated the GEHA Standard Option federal employee plan for the Maryland’s behavioral health benefit. Finally, the council designated the state’s current mandated habilitative services for individuals up age 19 and adopted the small group rehabilitative benefit for as the habilitative benefit for individuals over age 19.

Exchange Funding

The DHMH has received three federal grants: an Exchange Planning grant of $1 million; an Early Innovator grant of $6.2 million to develop an exchange IT infrastructure that could be replicated by other states; a Level One Establishment grant of $27 million to conduct data and policy analysis that will inform the technical and operational infrastructure of Maryland Health Connection and enable rapid implementation of the IT platform; and a Level Two Establishment Grant of $123 million to support continued policy development and consumer outreach, assistance, and education.

In addition, Maryland, along with nine other states, is receiving technical assistance from the Robert Wood Johnson Foundation through the State Health Reform Assistance Network; this assistance includes help with setting up health insurance exchanges, expanding Medicaid to newly eligible populations, streamlining eligibility and enrollment systems, instituting insurance market reforms and using data to drive decisions.

Next Steps

On December 7, 2012, Maryland received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based exchange. Final approval is contingent upon the state demonstrating its ability to perform all required Exchange activities on time, complying with future guidance and regulations, and acquiring legal authority to generate revenues that ensure operational sustainability.

Additional information about the Maryland Health Connection can be found at and the web portal at

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