2017 Broker Training
Molina Marketplace - WA
The Molina Story
The history behind our family tree
While working as an emergency room physician,
Dr. C. David Molina saw a need to change how the
health care system cared for people on a budget.
Dr. Molina believed that every patient should be
cared for like family.
In 1980, he opened a community clinic where
caring for people was more important than their
ability to pay.
Today, the legacy of Dr. Molina lives on through his
family, who lead Molina Healthcare, a company
that cares for more than 1.5 million members in 10
states. Serving people with Medicare and
Medicaid, Molina Healthcare remains true to Dr.
Molina’s convictions: treating each person like a
member of the family.
2017 looks to be the perfect “storm” for
Molina in Washington
Rates, Network, Expansion, Competition
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We Are Here to Stay!!
#201 on the Fortune 500 List
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2016 OEP Stats
2017 Marketplace Product
Our Mission Every decision we make, revolves around our core mission:
To provide quality healthcare services to financially
vulnerable families and individuals covered by government
programs
2017 Marketplace Priorities –
1. Retain our competitive position!
 Minimized the impact of plan design changes to keep
our premium rates low!
2. Provide new tools and services
 Making it easier for both you and members to do business
with us
3. Get people enrolled to avoid Tax Penalties
 Greater of 2.5% of income, or $695 per adult
4. Retain, Retain, Retain. Grow, Grow, Grow!
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Market Expansion for 2017 – All Markets
Expanded Marketplace County Footprint In Six Of Nine Existing States:
CA
WA
UT
MI
FL
TX
WI
OH
NM
Oran
ge
Coun
ty
SW – Clark,
Skamania
Spokane Collar –
Adams, Lincoln,
Ferry, Stevens,
Pend Oreille
Greater Columbia
– Kittitas
Box
Elder
Kent,
Washten
aw
Duval,
Hillsborou
gh,
Pinellas,
Polk,
Osceola
N/A
N/
A
Stark,
Madis
on
N/A
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Molina’s Value Proposition Over the Competition
1. We are near the lowest priced plan in
most of our states.
2. Deductible ONLY applies to OP Services
on most plans. Members just have a Copay
3. Labs and Radiology services have copays
NOT Coinsurance
4. System enhancements to cut down on
broker time
 My Molina (website for members)
 Molina Healthcare Website (Has new
“Broker Feature”)
 VUE Broker Portal
5. No Captive Sales Team, all leads go to
brokers
6. Strong broker support through our
dedicated broker support unit.
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Who is Eligible for Washington Health Benefit Exchange?
 Who is:
– Legal Washington residents
– Under 65
 Who’s not:
– Undocumented immigrants
– Currently incarcerated individuals
Molina Healthcare of Washington
Health Insurance Marketplace
Molina Marketplace in
Washington
2017 Product Changes
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Expanded into 8 New Counties
Standard Gold and Silver Plans are going
away (Standard Bronze was removed in
2016)
Telemedicine covered
Gender Reassignment Surgery covered
Non-routine non-emergency transport is
covered (e.g., Hospital to Hospital)
Acupuncture – No visit limitation when
done in conjunction with Substance abuse
treatment.
PA list updated
Preventive Care list of services updated
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9/29/2016
2017 Marketplace Product Portfolio
Washington
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Retained Current Washington Choice Plans
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Bronze, Silver & Gold Plans
Rationale – Secure closest match to Molina FFM Portfolio
Withdrew Molina Standard Product from the OIC and WHBE
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Impacts removal of Silver and Gold Portfolio

Rationale –
 Product offering is sub-optimal, and out of sync with standard Molina portfolio
 Requires maintenance of Non-ER Transportation
 Requires separate Rx Formulary Tier Structure and no mail order
 Includes Pediatric Vision cost share
 Retains Home Health Cost Share out of sync with Standard Molina Portfolio
 By retaining the Washington Choice Plans, we avoid market withdrawal
 While withdrawing the product, the OIC allows auto renewal to Choice Silver & Gold
product, so we retain guaranteed renewal, unless subscriber chooses a separate QHP
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2017 Marketplace Product – Universal Benefit Changes
Benefit Administration Changes

Office Visit Copayment – No more Copayment Stacking
• 2014-16 –
•
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Where multiple services occur “within a single office visit”, but where a benefit had differing member cost share, (i.e.
OV-$10, Lab-$15, Radiology $20), not the aggregate $45, but the highest copay $20 would be applied (Copayment
Stacking)
2017 •
The Office Visit Cost Share will apply for all services within a single office visit (regardless of whether multiple
services are performed). This will eliminate member and provider confusion on collection or cost share
responsibility, and reduce contact center calls and appeals
 ID Cards –
•
All Markets offering Molina Options Bronze – ID Card will show cost share for “first three visits” & “after first three
visits” PCP and Other Practitioner services
*Last year, more than 72 percent of people enrolled through the
Exchange received some form of subsidy to help offset their costs
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2017 Marketplace Product – WA Choice Plan Design Revisions
Bronze Plan
2016
2017
Medical/Rx Deductible - Increased
•
Ded waived for Preventive Services, Primary Care OV, Other
Practitioner OV, MH/SA OV, Generic Drugs, Preventive Drugs,
Family Planning, Pediatric Vision, and Hospice.
$5,000/$10,000
$6,650 / $13,300
Out of Pocket Maximum - Increased
$6,850 / $13,700
$7,150 / $14,300
Emergency Room Copay - Increased
$300 (after ded)
$350 (after ded)
Primary Care Copay – Increased, but without deductible
$25 (after ded)
$35
Other Practitioner Copay – Increased, but without deductible
$25 (after ded)
$35
Specialty Care Copay - Increased
$75 (after ded)
$80 (after ded)
Outpatient Mental Health & Substance Abuse Copay – Increased, but
without deductible
$25 (after ded)
$35
Outpatient Radiology - Increased
$75 (after ded)
$80 (after ded)
Outpatient Laboratory Services - Increased
$30 (after ded)
$35 (after ded)
Rx – Increased
• Tier 1 Drugs – Formulary Generic Drugs
• Tier 3 Drugs – Formulary Non-Preferred Brand Drugs
• Tier 4 Drugs – Formulary Specialty Drugs
$15
40% (after ded)
40% (after ded)
$33
50% (after ded)
50% (after ded)
Nutritional Counseling – Increased, but without deductible
$25 (after ded)
$35
Emergency Transportation - Revised
$100 Copay (after ded)
40% (after ded)
Phenylketonuria (PKU) – Testing and Treatment – Increased, but
without deductible
$25 (after ded)
$35
Diabetes Management – Other than Preventive – Increased, but without
deductible
$25 (after ded)
$35
Outpatient Dental Anesthesia – Increased
$75 (after ded)
$80 (after ded)
Dialysis Services - Increased
$75 (after ded)
$80 (after ded)
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2017 Marketplace Product – WA Plan Design Revisions
Silver 100 Plan
2016
2017
Medical Deductible – Increased
$50 / $100
$100 / $200
Out of Pocket Maximum - Reduced
$1,500 / $3,000
$800 / $1,600
Emergency Room - Increased
$100
$150
Specialty Care Copay - Reduced
$15
$10
Rx – Increased
• Tier 3 Drugs – Formulary Non-Preferred Brand Drugs
• Tier 4 Drugs – Formulary Specialty Drugs
10% (after Rx ded)
10% (after Rx ded)
20% (after Rx ded)
20% (after Rx ded)
2016
2017
Medical Deductible - Increased
$450 / $900
$575 / $1,150
Out of Pocket Maximum - Reduced
$2,250 / $4,500
$1,500 / $3,000
Emergency Room - Increased
$150
$200
Rx – Increased
• Tier 3 Drugs – Formulary Non-Preferred Brand Drugs
• Tier 4 Drugs – Formulary Specialty Drugs
20% (after Rx ded)
20% (after Rx ded)
30% (after Rx ded)
30% (after Rx ded)
2016
2017
Medical Deductible - Increased
$1,650 / $3,300
$2,175 / $4,350
Out of Pocket Maximum – Reduced
$5,450 / $10,900
$5,000 / $10,000
Emergency Room Copay - Increased
$300
$345
Rx – Increased
• Tier 3 Drugs – Formulary Non-Preferred Brand Drugs
• Tier 4 Drugs – Formulary Specialty Drugs
30% (after Rx ded)
30% (after Rx ded)
40% (after Rx ded)
40% (after Rx ded)
Silver 150 Plan
Silver 200 Plan
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2017 Marketplace Product – WA Plan Design Revisions
Silver 250 Plan
2016
2017
Medical Deductible - Increased
$2,000 / $4,000
$2,500 / $5,000
Out of Pocket Maximum- Reduced
$6,850 / $13,700
$6,350 / $12,700
Emergency Room Copay – Increased
$300
$350
Rx – Increased
• Tier 3 Drugs – Formulary Non-Preferred Brand Drugs
• Tier 4 Drugs – Formulary Specialty Drugs
30% (after Rx ded)
30% (after Rx ded)
40% (after Rx ded)
40% (after Rx ded)
2016
2017
Medical Deductible - Increased
$500 / $1,000
$1,500 / $3,000
Out of Pocket Maximum – Reduced
$6,850 / $13,700
$5,475 / $10,950
Emergency Room - Increased
$250
$300
Rx –
• Tier 1 Drugs – Formulary Generic Drugs
• Tier 3 Drugs – Formulary Non-Preferred Brand Drugs
• Tier 4 Drugs – Formulary Specialty Drugs
$15
20% (after Rx ded)
20% (after Rx ded)
$10
30% (after Rx ded)
30% (after Rx ded)
Gold Plan
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2017 Pharmacy Highlights
1. New Mail Order Benefit
 Improves affordability and access
 Applies to Tiers 1,2,3, and 5
(Specialty Drugs excluded)
 Easy On-line Ordering
2. Lower Copay for Generics
 Removes financial barriers to care
3. New Rx tier for Preventive Drugs
available at $0 copay
 Helps members know which
prescriptions are No Charge
4. New Expedited Review for NonFormulary Drugs
 Decision must be provided within 72
hours for standard requests and
within 24 hours for urgent requests
 Improves member access to nonformulary drugs
5. Prior authorization may be required
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Preliminary Rates for Washington in 2017
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Provider Network
Main Provider Groups
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UW
Swedish
Providence
MultiCare Health
Sea Mar (FQHC)
Rockwood
Columbia Community
Confluence Health
HealthPoint (FQHC)
Vancouver Clinic
Note: *Franciscan not with Marketplace, Medicare/Medicaid only
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Referral vs. Authorization
Referral
• Molina Healthcare does not require referrals for contracted
specialists.
• In referring a patient, the PCP should forward pertinent member
information and findings to the specialist.
• Some specialists may require referrals (however Molina does
not)
Authorization
• designed to assure the medical necessity of service, prevent
unanticipated denials of coverage,
• ensure participating providers are utilized, and
• all services are provided at the appropriate level of care for the
member’s needs.
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My Molina
New Features
Member
Registration
View/Pay My Bill
Available
Services
Contact Us
Marketplace
Member
Portal
Account Setting
Benefit and
Eligibility
Health Records
Member ID
Cards
My Doctor
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© 2013 Molina Healthcare, Inc.
Donald Duck
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© 2013 Molina Healthcare, Inc.
Ways to Pay
Walk-in locations
nationwide
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Marketplace Broker Support
Welcome to MolinaMarketplace.com
Easy Access to Broker Support Tools
BSU Contact Information
Phone: (855) 885-3179 (New number)
Monday through Friday – 7:00 AM to 6:00 PM (MST)
Broker Services Department: Option 1
Commission Department: Option 2
Contracting Department: Option 3
Email: [email protected]
Broker Support Unit Team:
• Jamie Neslen, Manager
• Rhonda Clarke, Supervisor Broker Services
• Rebecca Perley, Supervisor Contracting & Onboarding
• Suza Capps, Supervisor Commission Recon
Broker Support Unit (BSU)
Broker
Services
Contracting
Reconciliation/
Commissions
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Significant Trainings = SME
Fully staffed, Increased Spanish Speaking Capacity
Dedicated phone number
CARE Team (next slide)
• Streamlined contracting process
• Utilizing Technology – Broker Portal
• DocuSign and eSignature
• Identify and resolve commission discrepancies
• Manage broker recon
• Manual review of AOR exceptions
Ways we can help:
• Marketing Material Distribution
• Broker Communications, i.e., eBlasts
• Process your Molina appointment and contracting to sell our MP
products
• Member Look Up/Issues
• Commission Questions/Issues
WE ARE EXCITED TO INTRODUCE THE
Marketplace Broker Communication And Resolution Experts Team!
(MP BROKER CARE TEAM)
Los
Angeles
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San Bernardino
San
Diego
Riverside
Imperial
Access to Care
Billing Issue
Claims
Enrollment
Member Services
Prior Authorization Status
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Marketplace Marketing Materials
Molina Marketplace Materials
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2017 Open Enrollment Period
• Marketplace open enrollment dates:
 November 1, 2016 – January 31, 2017
• Molina’s website www.MolinaHealthcare.com will provide 2017 plan
information starting October 1, 2016
• Someone who enrolls by December 15, 2016 will have a January 1, 2017
effective date
• Some individuals may qualify for a 60 day Special Election Period (SEP)
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Molina Marketplace- Washington Contact
James Maguire
Washington Broker Manager
Email: [email protected]
Contact Phone #- 253-441-9182
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Questions