1
Molina Marketplace Presentation
Molina Healthcare of New Mexico
Community Outreach
© 2013 Molina Healthcare, Inc.
Who is Molina Healthcare?
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 Molina Healthcare was founded more than 30 years go by C. David Molina,
MD and is the fastest growing and experienced managed care health
companies in the country- offering medical insurance under Medicaid,
Medicare and other government sponsored programs. Serving over 1.9 Million
Members 11 states, and approximately 170,000 in New Mexico.
 Molina Healthcare is a family founded company and today is still a physicianled organization.
 Works Exclusively for people receiving health care coverage from
government-sponsored, publicly-funded programs like Medicaid and
Medicare.
 Serving low-income populations who have traditionally faced barriers to
quality of health care.
Molina Healthcare of NM- is pleased
to have been selected by the Human
Services Department (HSD)
to serve as a
Centennial Care Managed Care
Organization!
New Mexico’s #1 Ranked
Medicaid Plan for third year in
a row by Consumer Reports
and NCQA
© 2013 Molina Healthcare, Inc.
Molina
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Our Mission then and now - To
provide quality healthcare
services to financially
vulnerable families and
individuals
0 – 138%
(Medicaid FPL)
139 – 250%
(Health Insurance
Marketplace)
Molina’s
• Medicaid Expansion
• Centennial Care
• Marketplace
• Medicare MA-SNP
• Medicare MAPD
© 2013 Molina Healthcare, Inc.
“ONE
MOLINA”
We’ve Got You
Covered!
Key Positioning Attributes with Consumers, Navigators & CBOs
1.
2.
Molina has over 30 years of experience
•
Many that are in the Individual business today, do not cater to a low income population
•
They don’t have the knowledge or support mechanisms that we can provide
All Plan Designs are not the same
•
3.
We may compete on a metal by metal basis, but understand the differences in design
Pricing is not always a good comparison
•
Where we are positioned at a competitive price, our value and experience is the difference
•
Deductibles and copay ‘s
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Our Plan selections - How benefits encourage access and low cost share
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Value Added services - 24 hour nurse line, website services, health education programs
© 2013 Molina Healthcare, Inc.
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“Key Lingo” of the Marketplace
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Product Feature
Description
Monthly premiums
Monthly amount paid to health plan in return for
healthcare coverage
Premium Subsidy
When a 3rd party covers part, or all, of the
monthly premium for somebody's health
insurance
Medicaid
Marketplace
No
Yes
Yes
(gov't. subsidizes 100%)
Yes
(gov't. subsidizes 50% - 100%)
No
Yes
Yes
(100%)
Yes
(60-90%)
Federal government provides a tax credit that
Advanced premium tax
can be used for covering monthly premiums;
credit (APTC)
this is the subsidy for marketplace members
Actuarial Value (AV)
The percentage of cost for covered benefits that
a plan will cover
Deductible
Fixed dollar amount member must pay before
insurance starts paying anything
No
Yes
Co-payment
Fixed dollar amount member pays after their
deductible, every time they visit the doctor
No
Yes
250%+ FPL
Our success will be determined on how well we assess the consumer’s
understanding and guiding them to the right choice – Molina!
• A key to selecting Molina, and ultimately their satisfaction and retention.
• An Opportunity for you to be recognized as a trustworthy guide
© 2013 Molina Healthcare, Inc.
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“Key Lingo” of the Marketplace
Product Feature
Description
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Medicaid
Marketplace
Co-insurance
Portion of the cost of a procedure that member
must pay - applied to high $ hospital procedures
usually
No
Yes
Cost sharing subsidy
When a 3rd party pays part of someone's copayments and co-insurance (low FPL - low
copay)
NA
Yes
NA
Yes
NA
Fixed dollar amount that member can be
Out of pocket
expected to pay a year in combined deductibles,
maximums (OOP Max)
co-payments, and co-insurance
Guaranteed Issue
No medical underwriting/health related
qualifying questions will be asked
NA
First dollar coverage
A set number of services where deductibles and
co-pays are waived. (e.g. PCP preventive care,
urgent care, pre, post neonatal, MH/SH visits)
NA
© 2013 Molina Healthcare, Inc.
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250%+ FPL
Yes
Eligibility for the Marketplace
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Who is eligible to enroll in the Marketplace?
•
•
•
•
•
Anyone who is in the United States legally, does not have access to another form
of health insurance, such as Medicare, Medicaid, an employer provided health
plan is eligible to enroll for coverage through the Marketplace.
Molina is offering six (6) Marketplace plans: Bronze, Silver (4 different plans)
and Gold. More about each of these levels will be discussed shortly.
Depending on an applicant’s individual or family (if applying for family
coverage) Federal Poverty Level (FPL), there may be tax credits to help pay for
the cost of the coverage.
The FPL range for which premium assistance tax credits may be provided is
between 100% and 250% of FPL.
Applicants who do not qualify for a tax credit, will be required to pay the full
amount of their individual or family premium.
© 2013 Molina Healthcare, Inc.
Enrolling in the Marketplace
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How does an applicant enroll in the Marketplace?
•
•
•
•
•
The preferred method for enrolling in the Marketplace is by accessing the
federal website: www.healthcare.gov.
New Mexico has a joint Federal/State marketplace for calendar year 2014. The
State has ceded responsibility to the federal government for enrollment and
eligibility functions. It is expected that New Mexico will be a fully state run
Marketplace for calendar year 2015.
New Mexico as a joint Federal/State marketplace for calendar year 2014, is also
allowing the use of the state Marketplace website for access to the federal
enrollment site. The state website for enrollment is: www.BeWellNM.com.
Due to difficulties accessing the on-line enrollment sites, two additional methods
of enrollment are being considered: 1) paper enrollment and 2) enrollment
through each carrier’s website. The Molina website is:
http://author.molinahealthcare.com/members/nm/enus/hp/marketplace/Pages/marketplace.aspx.
Intensive efforts are underway to fix the website enrollment problems.
© 2013 Molina Healthcare, Inc.
APTC & Cost Sharing
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If your individual income is between $11,490 – $45,960, you may qualify for financial assistance
The lower your income, the greater the tax credit you will get, and the less you will have to pay out of
your own pocket in monthly premiums
Advanced Premium Tax Credit (APTC)
•
•
•
•
•
Must meet certain income requirements
Cannot have “deemed” coverage from
an employer
Cannot currently be on Medicaid or other
government programs
Available to all medal level plans
Tax credits can be immediately applied to the
monthly premium you pay
Cost-sharing Subsidies:
•
•
•
Reduce out-of-pocket health care expenses
Co-payments and deductibles
Only Available If You Buy A Silver Plan On The Marketplace
Think about it: If you qualify as a low-income individual (annual income between $14,000 and
$23,000), the Silver Plan will be the best product because the federal government will reduce your
monthly premium through tax credits and your cost sharing expenses when you see the doctor through
the cost-sharing subsidies.
© 2013 Molina Healthcare, Inc.
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Unique Services
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Acupuncture -- Limited to 20 visits per calendar year.
•
Bariatric Surgery – A member must complete the medical group-approved pre-surgical educational
preparatory program regarding lifestyle changes.
•
Chiropractic – Limited to 20 visits per calendar year.
•
Health Education – These materials cover such topic as nutrition, stress management, child safety,
asthma, and diabetes.
•
Non-emergency Transportation – Members can access transportation to medical services. Limited
to 4 round trip trips a month and requires arrangements in advance.
•
Smoking Cessation – This program offers smoking cessation services to all smokers interested in
quitting. Specialized services are available for teens, pregnant smokers and tobacco chewers.
•
Weight Control Programs – These programs are offered for member s 17 and older. They will learn
about healthy eating and exercise. Participates must agree to program criteria.
© 2013 Molina Healthcare, Inc.
Benefits At-A-Glance
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Molina Marketplace
2014 Benefits-At-A-Glance
Bronze MBN-001
Silve r MSN-100
Silve r MSN-150
Silve r MSN-200
Silve r MSN-250
Gold MGN-001
Fe a ture s6
Annual Deductible (individual/family)
Prescription Drug Deductible
(individual/family)
Annual Out-of-Pocket Maximum
(individual/family)
Be ne fits
Eme rge ncy a nd Urge nt Ca re
Emergency Room 7
Urgent Care
Office Visits4
Preventive Care
Prenatal Visits
Well-child Visits
Family Planning
Primary Care
Specialty Care
Other Practitioner Care
Habilitative Care
Rehabilitative Care
Mental Health Services
Substance Abuse services
Pe dia tric Vision Se rvice s8
Vison Exam
Glasses
Contacts
Pre scription Drugs
Formulary Generic Drugs
Formulary Preferred Brand Drugs
Formulary Non Preferred Brand
Drugs
Specialty Drugs
Outpa tie nt Hospita l / Fa cility
Se rvice s
Laboratory Services
Radiology Services
Specialized Scanning Services
(CT, MRI, PET Scans)
Medical/Surgical Services
Inpa tie nt Hospita l Se rvice s
Medical/Surgical, Maternity Care,
Mental Health, Substance Abuse,
Skilled Nursing Facility
Hospice Care
Tra nsporta tion Assista nce
Emergency Transportation Ambulance
Non-Emergency Medical
Transportation to & from Medical
Appointments 5
Supple me nta l Be ne fits
24-Hour Nurse Advice Line
Weight control program
Motherhood Matters ® , mothers-tobe program
Tobacco counseling, smoking
cessation program
$4,000/$8,0009
2
$0
$1,500/$3,0001
$0
$1,700/$3,4001
3
$200/$400
$250/$5001
$0
$0
$0
$0
$6,350/$12,700
$2,250/$4,500
$2,250/$4,500
$5,200/$10,400
$6,350/$12,700
$6,350/$12,700
$300 co-pay
$100 co-pay
$100 co-pay
$15 co-pay
$150 co-pay
$30 co-pay
$250 co-pay
$60 co-pay
$250 co-pay
$75 co-pay
$250 co-pay
$60 co-pay
$40 co-pay
$65 co-pay
$65 co-pay
30% coinsurance
30% coinsurance
$65 co-pay
$65 co-pay
$20 co-pay
$50 co-pay
$50 co-pay
20% coinsurance
20% coinsurance
$50 co-pay
$50 co-pay
$300/$600
No Charge
$15 co-pay
$40 co-pay
$40 co-pay
25% coinsurance
25% coinsurance
$40 co-pay
$40 co-pay
$30 co-pay
$60 co-pay
$60 co-pay
30% coinsurance
30% coinsurance
$60 co-pay
$60 co-pay
$45 co-pay
$75 co-pay
$75 co-pay
40% coinsurance
40% coinsurance
$75 co-pay
$75 co-pay
$0 co-pay
$10 co-pay
$10 co-pay
10% coinsurance
10% coinsurance
$10 co-pay
$10 co-pay
$45 co-pay
$45 co-pay
$0 co-pay
$0 co-pay
No charge
$30 co-pay
$15 co-pay
$30 co-pay
$15 co-pay
$40 co-pay
$40 co-pay
$20 co-pay
$20 co-pay
$25 co-pay
$75 co-pay
$3 co-pay
$8 co-pay
$10 co-pay
$20 co-pay
$20 co-pay
$40 co-pay
$20 co-pay
$55 co-pay
$20 co-pay
$50 co-pay
40% coinsurance
40% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
25% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
20% coinsurance
20% coinsurance
$45 co-pay
$75 co-pay
$0 co-pay
$10 co-pay
$15 co-pay
$40 co-pay
$30 co-pay
$60 co-pay
$40 co-pay
$65 co-pay
$20 co-pay
$50 co-pay
40% coinsurance
40% coinsurance
10% coinsurance
10% coinsurance
25% coinsurance
25% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
30% coinsurance
20% coinsurance
20% coinsurance
40% coinsurance
10% coinsurance
30% coinsurance
25% coinsurance
0% coinsurance
30% coinsurance
20% coinsurance
$100 co-pay per
trip
$100 co-pay per
trip
$150 co-pay per
trip
$250 co-pay per
trip
$250 co-pay per
trip
$250 co-pay per
trip
Not Covered
$5 co-pay per
round trip
$10 co-pay per
round trip
$10 co-pay per
round trip
$10 co-pay per
round trip
Not Covered
No Charge
© 2013 Molina Healthcare, Inc.
Rate Chart
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Region
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
Metal Tier
Age
0-20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
Gold
Silver
Bronze
Gold
Silver
Bronze
Gold
Silver
Bronze
Gold
Silver
Bronze
Gold
Silver
Bronze
118.42
186.49
186.49
186.49
186.49
187.24
190.97
195.45
202.72
208.69
211.67
216.15
220.62
223.42
226.40
227.90
229.39
230.88
232.37
235.36
238.34
242.82
247.11
253.07
260.53
269.30
105.50
466.14
166.14
166.14
166.14
166.80
170.12
174.11
180.59
185.91
188.57
192.55
196.54
199.03
201.69
203.02
204.35
205.68
207.01
209.67
212.32
216.31
220.13
225.45
232.09
239.90
92.82
146.15
146.15
146.15
146.15
146.74
149.66
153.17
158.87
163.55
165.89
169.39
172.90
175.09
177.43
178.60
179.77
180.94
182.11
184.45
186.79
190.29
193.66
198.33
204.18
211.05
131.34
206.84
206.84
206.84
206.84
207.66
211.80
216.76
224.83
231.45
234.76
239.72
244.69
247.79
251.10
252.75
254.41
256.06
257.72
261.03
264.34
269.30
274.06
280.68
288.95
298.67
117.00
184.26
184.26
184.26
184.26
184.99
188.68
193.10
200.29
206.18
209.13
213.55
217.98
220.74
223.69
225.16
226.64
228.11
229.58
232.53
235.48
239.90
244.14
250.04
257.41
266.07
102.93
162.10
162.10
162.10
162.10
162.74
165.99
169.88
176.20
181.39
183.98
187.87
191.76
194.19
196.78
198.08
199.38
200.67
201.97
204.56
207.16
211.05
214.78
219.96
226.45
234.07
161.42
254.21
254.21
254.21
254.21
255.22
260.31
266.41
276.32
284.46
288.52
294.63
300.73
304.54
308.61
310.64
312.67
314.71
316.74
320.81
324.88
330.98
336.82
344.96
355.13
367.07
143.80
226.46
226.46
226.46
226.46
227.36
231.89
237.33
246.16
253.41
257.03
262.46
267.90
271.30
274.92
276.73
278.54
280.35
282.17
285.79
289.41
294.85
300.06
307.30
316.36
327.00
126.50
199.22
199.22
199.22
199.22
200.02
204.00
208.78
216.55
222.93
226.12
230.90
235.68
238.67
241.85
243.45
245.04
246.63
248.23
251.42
254.60
259.38
263.97
270.34
278.31
287.67
144.24
227.16
227.16
227.16
227.16
228.06
232.61
238.06
246.92
254.19
257.82
263.27
268.72
272.13
275.77
277.58
279.40
281.22
283.04
286.67
290.30
295.76
300.98
308.25
317.34
328.01
128.50
202.36
202.36
202.36
202.36
203.17
207.22
212.07
219.96
226.44
229.68
234.53
239.39
242.43
245.66
247.28
248.90
250.52
252.14
255.38
258.61
263.47
268.13
274.60
282.70
292.21
113.04
178.02
178.02
178.02
178.02
178.73
182.29
186.57
193.51
199.20
202.05
206.33
210.60
213.27
216.12
217.54
218.97
220.39
221.81
224.66
227.51
231.78
235.88
241.57
248.69
257.06
161.42
254.21
254.21
254.21
254.21
255.22
260.31
266.41
276.32
274.46
288.52
294.63
300.73
304.54
308.61
310.64
312.67
314.71
316.74
320.81
324.88
330.98
336.82
344.96
355.13
367.07
143.80
226.46
226.46
226.46
226.46
227.36
231.89
237.33
246.16
253.41
257.03
262.46
267.90
271.30
274.92
276.73
278.54
280.35
282.17
285.79
289.41
294.85
300.06
307.30
316.36
327.00
126.50
199.22
199.22
199.22
199.22
200.02
204.00
208.78
216.55
222.93
226.12
230.90
235.68
238.67
241.85
243.45
245.04
246.63
248.23
251.42
254.60
259.38
263.97
270.34
278.31
287.67
© 2013 Molina Healthcare, Inc.
APTC: Example of an Individual
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John is 24 years old non smoker and has an annual income of
$22,980, which equals 200 percent of the poverty line. His
expected contribution is 6.3 percent of his income, or $1,448
a year. The benchmark plan available to John is priced at
$5,000; John would be eligible for a credit amount of $3,552
($5,000 minus $1,448).
Income
FPL Level
Premium w/o APTC
Expected Contribution %
Credit Amount
Monthly Credit
Monthly Premium w/ APTC
$22,980
200%
$416.67
6.30% $1,447.74
$3,552.26
$296.02
$120.65
© 2013 Molina Healthcare, Inc.
APTC: Example of a Family of Four
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Peter, Mary and their two children have an annual income of $52,988, which translates to
225 percent of the federal poverty line. At this income level, the family’s expected
contribution is 7.18 percent of their income, or $3,805 a year. In the area where Peter and
Mary live, the total premiums for the benchmark plan that would cover all members of the
family is $15,000. The credit amount that the family would be eligible for is $11,195, which
is $933 a month. ($15,000 minus their expected premium contribution of $3,802). An
advance payment of $933 a month will be paid directly to the insurer offering the health plan
that the family selects; the family would be responsible for paying the remaining premium to
the insurer.
Income
FPL Level
Premium w/o APTC
Expected Contribution %
Credit Amount
Monthly Credit
Monthly Premium w/ APTC
$
$
$
$
$
© 2013 Molina Healthcare, Inc.
52,988
225%
1,250
7.18% $
11,195
932.96
317.04
3,805
New Mexico Marketplace Competitors
Who is participating in the Marketplace?
There are five (5) carriers participating in the New Mexico Marketplace:
•
•
•
•
•
Health Care Service Corporation (BC/BS)
Lovelace Health Systems
MOLINA Healthcare of New Mexico
New Mexico Health Connections
Presbyterian Health Plan
For premium rating, New Mexico has been divided into five (5) regions (next to
each region is Molina’s premium ranking status):
• Region 1 (Albuquerque) - 2
• Region 2 (Farmington) - 1
• Region 3 (Las Cruces) - 5
• Region 4 (Santa Fe) - 3
• Region 5 (Rural/All Other) - 3
© 2013 Molina Healthcare, Inc.
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MMG: Community Perspective
Committed to providing Access, Quality & Affordability
•
•
•
•
MMGS remove barriers for our members
Clinics located in areas where our members Shop, Eat, Play & Pray
Give back to the community through free transportation
Great reputation within the community
© 2013 Molina Healthcare, Inc.
17
Questions
© 2013 Molina Healthcare, Inc.