December 20, 2012 The Honorable Kathleen Sebelius Secretary US Department of Health and Human Services 200 Independence

Avenue, SW Washington, DC 20201 Dear Madame Secretary, Governor Gary Herbert submitted a blueprint requesting that HHS allow Utah to pursue a State-Based Exchange and that the federal government certify Utahs Avenue H Exchange as an Affordable Care Act compliant exchange. Unfortunately, the State of Utah has consulted with very few, if any, stakeholders and consumers in the development of its State-Based Exchange blueprint. As Utah based advocates for children, families, seniors, and health care providers, this lack of transparency has created a number of questions and concerns. We request the Secretarys assistance in ensuring that these questions and concerns are addressed before certifcation of Avenue H as the Utah StateBased Exchange. 1. Lack of Transparency How will the state ensure transparency in the decision-making process as Utahs exchange is further designed? As you know, Exchanges will have wide impact. The creation of consumer assistance programs, the regulation of Qualifed Health Plans (QHP), the distribution of cost and quality information impacts almost every provider, health plan, business, and family in the state. It is very important that the Exchange be designed with input from consumers and stakeholders who will be impacted. This lack of transparency drives many of the following questions and concerns. 2. Governance What governance structure does Utah plan to use, and how will that structure ensure transparency and an open process to the public? Utahs current exchange is governed by the Utah Risk Adjuster Board, a body made up exclusively of health plans and insurance producers. A governing body with a wider range of stakeholders, including providers and consumers, will lead to a more effective and successful exchange. 3. Consumer protections What consumer protections (e.g. confict of interest standards, internal reviews and external appeals, quality reporting, and administrative simplicity) will be implemented? 4. Consumer assistance

How will the state establish and run a consumer assistance program that ensures culturally competent, concise, comparative information on benefts, quality, costs and access to providers and services? How will the Navigator program be implemented and funded, and what will be the process for selecting and determining if Navigators are meeting the goals of the program? 5. Health plan regulation How does the state plan to manage health plans sold on the exchange, including the collection and analysis of plan information, oversight of QHPs, and the determination that QHPs meet established standards? How does the state plan to certify and regulate QHPs sold on the exchange? Particularly, how does the exchange plan to ensure that QHPs are meeting the minimum beneft requirements outlined in the states essential health benefts benchmark? Utahs Essential Health Beneft Plan selection, PEHP Basic, currently violates HHS guidance and proposed rules regarding mental health parity and childrens dental and vision care. How does Utah propose supplementing our EHB and ensuring health plans comply? Will the state establish standards and require QHPs to provide information about beneft design, rates, and quality reporting/improvement? 6. Network adequacy How will Utahs Exchange defne network adequacy and how will it determine whether QHPs meet service area and network adequacy requirements? 7. Essential Community Provider Network Geographic Suffciency How will the Exchange determine if QHPs have demonstrated suffcient geographic distribution of essential community providers? Will the Exchange require a balance of hospitals and non-hospital providers that serve low-income populations? How will the Exchange determine if organizations are exempt from the essential community provider contracting requirement, and how will QHPs need to document that they can meet the needs of low-income, medically underserved individuals if they are requesting an exemption? 8. Integration with Medicaid and CHIP

The majority of Utahs uninsured children are income eligible for Medicaid and CHIP , but not enrolled. How will the Exchange help these children access and enroll in coverage? What policies can be established that will ensure continuity of care for individuals moving between public programs and private coverage on the Exchange? We believe all of the questions outlined above must be suffciently addressed before Utahs Exchange is certifed, provisionally or otherwise, as compliant with the ACA. Thank you for considering our concerns as you work with the State of Utah on reviewing its application to run a State-Based Exchange. Sincerely, AARP of Utah The Association of Utah Community Health The Disability Law Center NAMI Utah Utah Chapter of the American Academy of Pediatrics Voices for Utah Children