Washington Health Benefit Exchange · The Washington Health Benefit Exchange As laid out in...
Transcript of Washington Health Benefit Exchange · The Washington Health Benefit Exchange As laid out in...
DISCLAIMER;The views and information expressed are my personal opinions and perspectives and do not represent the official position of the State of Washington or the Washington Health Benefit Exchange Board or Staff.
The Washington Health Benefit Exchange
As laid out in Substitute Senate Bill 5445, twenty nominations for the Exchange Board were submitted by the house and senate caucuses and included individuals with expertise in individual health care coverage, small employer health care coverage, health benefits plan administration, health care finance and economics, actuarial science, and/or administering a public or private health care delivery system. Initial members of the board will serve staggered terms not to exceed four years. On March 15th, 2012, the Board assumed governing authority over the Exchange.
The Exchange Board Chair: Margaret Stanley, retired Executive Director of the Puget Sound Health Alliance, and
former Senior Vice‐President at Regence BlueShield and head of public employee benefits programs in both Washington and California (Non Voting with exception of Tie Votes)
Ben Danielson, MD Medical Director at the Odessa Brown Children's Clinic
Bill Baldwin, Partner, The Partners Group
Don Conant, General Manager at Valley Nut and Bolt in Olympia and Assistant Professor in the School of Business at St. Martin's University
Doug Conrad, Professor of Health Services at the University of Washington School of Public Health
Melanie Curtice, partner in the employee benefits section at the law firm of Stoel Rives LLP
Phil Dyer, Senior Vice President at Kibble & Prentice/USI and former state legislator
Steve Appel, wheat and barley farmer and immediate past‐President of the Washington Farm Bureau
Teresa Mosqueda, Legislative and Policy Director for the Washington State Labor Council and Chair of the Healthy Washington Coalition
Ex‐Officio: Dorothy Frost Teeter, Director of the Health Care Authority
Ex‐Officio: Mike Kreidler, Washington State Insurance Commissioner
The Exchange Board Goals
▪ Increase access to affordable health plans.
▪ Organize a transparent and accountable insurance market ‐‐ to facilitate consumer choice.
▪ Provide an efficient, accurate and customer‐friendly eligibility determination process.
▪ Enhance health plan competition on value ‐‐ price, access, quality, service, and innovation.
The Exchange Major Committees
Operations Chair, Melanie Curtice
o Steve AppeloBill BaldwinoDon ConantMargaret Stanley
Policy Chair, Teresa Mosqueda
oDoug ConradoBen DanielsonoPhil DyerMargaret Stanley
Exchange Board Advisory CommitteeMay 16, 2012 the Exchange Board selected 17 committee members to provide expertise and experience on an array of issues related to developing the Health Benefit Exchange in Washington State. Those members include:
▪ American Indian Health Commission (AIHC) Representative ▪ Sharon Beaudoin, WithinReach▪ Ted Blotsky, Employee Benefit Services‐Associated Employers Trust▪ Glen Bogner, Molina Healthcare▪ Kitti Cramer, Premera▪ Mike Fournier, Washington Farm Bureau▪ Patty Hayes, Public Health – Seattle & King County▪ Dhyan Lal, Providence Health & Services▪ Mary McWilliams, Puget Sound Health Alliance▪ Karen Merrikin, GroupHealth Cooperative▪ Hiroshi Nakano, South Sound Neurosurgery▪ Pam Oliver, Community Member▪ Jim Pinkerton, Regence ▪ Donna Steward, Association of Washington Business▪ Larry Thompson, Whatcom Alliance for Healthcare Access▪ Washington Association of Health Underwriters (WAHU) Representative▪ Joshua Welter, Mainstreet Alliance
Exchange Board Technical Advisory Committees
Dental Technical Advisory Committee ▪ Dr. Christopher Delecki – Odessa Brown Children’s Clinic ▪ David Digiuseppe – Community Health Plan of Washington ▪ Bracken Killpack ‐Washington State Dental Association ▪ Dr. Alejandro Navarez – Sea Mar CHC ▪ Dr. Brian Schur – Tri‐Cities Community Health Center ▪ Chris Smith – Regence BlueShield ▪ Delta Dental Washington Dental Service Foundation Representative
Navigator Program Technical Advisory Committee ▪ Sofia Aragon – Washington State Nurses Association ▪ Rhonda Hauff – Yakima Neighborhood Health Services ▪ Devon Love – Equal State Community Coalition for Multicultural Health ▪ Vicki Lowe – Jamestown S’Klallam Tribe ▪ Michelle Sarju – Open Arms Perinatal Services ▪ Lara Welker – Whatcom Alliance for Healthcare Access ▪ Bethany Phenix – Community Minded Enterprises▪ Jon Gould – Children’s Alliance
Role of Agents/Brokers Technical Advisory Committee ▪ Lonnie Goodell – Group Health Cooperative ▪ Dave Guyll – Conover Insurance ▪ Bryan Marsh – Regence BlueShield ▪ Nita Petry – Gallagher Benefit Services, Inc. ▪ Harald Schot – LifePlan Financial Inc.
Health Care National Spending(Deloitte)
This year, the federal government will take in about $2.4 trillion and spend about $3.6 trillion—the fourth year in a row of the deficit exceeding $1 trillion.
Spending for health care programs—Medicare, Medicaid, Children’s Health Insurance Program (CHIP), military health, federal employee coverage—will be almost one‐fourth of the government’s outlays and a third of all government revenues from taxes paid by individuals and companies
Health Insurance Exchange Status of State Action
Source: The Kaiser Family Foundation,statehealthfacts.org Data Source: State Action Toward Creating Health Insurance Exchanges, as of Dec 10, 2012. Accessed December 10, 2012.
Washington is a Leading State in the Process of Securing $178 Million for Exchange Establishment & Medicaid Eligibility Systems
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Building The Exchange
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• HCA receives one‐year $22.9 million grant to design and develop Exchange
• SSB 5445 passed creating Exchange as “public private partnership”
• Governor names Exchange Board members
• Board begins governing authority• ESSHB 2319 passed
• Deloitte Consulting, LLP, signs on as system integrator
• Exchange names first CEO and moves into new building
• Washington becomes second Level 2 establishment grant recipient, $128 million
• Exchange moves onto own payroll and accounting systems
• Sustainability plan submitted to Legislature
• WA HBE receives conditional approval from HHS/CCIIO to operate the state exchange
• Exchange must be certified by HHS• Additional legislative action taken as needed
• Open Enrollment begins (October 1)
2011
20122013
2014• Coverage purchased in the Exchange begins
• Open enrollment ends March 31.
• Year 2 open enrollment in Oct.
Exchange Functions
▪ Certifying health plans as “Qualified Health Plans” to be offered in the exchange.o The final rule allows Exchanges to work with health insurers on structuring qualified health plan choices that are in the best interest of their customers. This could mean that the Exchange allows any health plan meeting the standards to participate or that the Exchange creates a competitive process for health plans to gain access to customers on the Exchange
▪ Standards for Health Planso Exchanges, working with state insurance departments, to set specific standards to ensure that each qualified health plan gives consumers access to a variety of providers within a reasonable amount of time. Exchanges will also establish marketing standards to make sure that qualified health plans do not market plans in a way that discriminates against people with illnesses.
Operating a website to facilitate comparisons among qualified health plans for consumers
Operating a toll‐free hotline for consumer support, providing grant funding to entities called “Navigators” for consumer assistance, and conducting outreach and education to consumers regarding Exchanges
Exchange Functions Consumer Interactions
Affordable Care Act TerminologyIllustration
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Plan
Product
Issuer Issuer
Product 1
Plan 1 Plan 2
Product 2
Plan 3 Plan 4
Plan Management Timeline (draft version 12/13/12)
1/13
2012
11/12 3/13
2013
12/12 2/13 4/13 5/13 6/13 7/13 8/13 9/13 10/13 11/13 12/13 1/14 2/14
2014
Target Board Approval of QHPs August 21, 2013
SERFF completes Plan Management enhancements
Carrier training &filing instructions
Open enrollment (10/1/13 through 3/31/14)
Carriers submit HBE Certification Information for QHP review by HBE
CMS delivers final templates & data validation service
Carrier & HBE Plan Management system testing
OIC Regulatory Review
HBE Market Place
3rd Party Verification
Review of Rate Filing & Binder (Plan Data – Data
Templates)
Carrier Ratification of Plan data on Healthplanfinder
CCIIO Financial ManagementCCIIO data templates for Certified Plans sent to CCIIO by July 31, 2013
Review of Product Filing (initial Form Filing)
Product Filings dueApril 1, 2013
Rate & Binder Filings due May 1, 2013
Carriers load ProductCarriers load Rate Filing
and Binder
Carriers submit final Approved Plan Data to HBE
Exchange Functions
Determining eligibility of consumers for enrollment in qualified health plans and for insurance affordability programs (premium tax credits, Medicaid, CHIP and the Basic Health Plan)
▪ Eligibility Determinations: Exchanges to consider whether consumers are eligible for all available programs using a single, streamlined application
▪ Simple Verification of Data: Exchanges to rely on existing electronic sources of data to the maximum extent possible to verify relevant information, with high levels of privacy and security protection for consumers.
▪ Coordinating across Programs: The final rule ensures that Exchanges will coordinate with Medicaid, CHIP, and the Basic Health Program
Exchange Value – Specific Functions
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I. Issuers of QHPs
II. Health Care Market
III. Public and State
• Marketing & Outreach• Eligibility Determination for tax
credits• Enrollment• Premium Aggregation
• Easy plan comparison and purchase of health insurance
• Reporting of cost/quality metrics
• Awareness of need for health insurance
• Appeals of eligibility determinations and individual responsibility
• Information on health insurance carriers
• Customer Service• Enrollment reconciliation with
HHS• New Membership opportunity –
previously uninsured
• Supporting use of innovative product designs and payment methodologies
• Expanded access to health insurance coverage
• Reduced charity care
• Trustworthy source of health care reform information
• Broad‐based Public Information • Other impacts of ACA
Exchange FunctionsExchanges to build partnerships with and award grants to entities known as “Navigators” who will reach out to employers and employees, consumers, and self‐employed individuals to:
Conduct public education activities to raise awareness about qualified health plans
Distribute fair and impartial information about enrollment in qualified health plans, premium tax credits, and cost‐sharing reductions
Assist consumers in selecting qualified health plans Provide referrals to an applicable consumer assistance program or ombudsman in the case of grievances, complaints, or questions regarding health plans or coverage
Provide information in a manner that is culturally and linguistically appropriate
Exchange Functions
SMALL BUSINESS HEALTH OPTIONS (SHOP)
• Exchanges will operate a Small Business Health Options Program (SHOP). SHOP will allow employers to choose the level of coverage they will offer and offer the employees choices of all qualified health plans within that level of coverage. This allows employees a choice among plans and can select the one that best fits their needs and their budget. Employers can offer coverage from multiple insurers, just like larger companies and government employee plans, but get a single bill and write a single check. SHOP Exchanges can also allow employers to select a single plan to offer its employee
• Starting in 2014, small employers purchasing coverage through SHOP may be eligible for a tax credit of up to 50% of their premium payments if they have 25 or fewer employees, pay employees an average annual wage of less than $50,000, offer all full time employees coverage, and pay at least 50% of the premium.
Exchange Functions and Services
Develop, Host
Website Customer Support, Quality Rating System
Determine Eligibility, Tax Credits
Aggregate Premiums
Review & Certify
Qualified Plans
Highlight Products, Oversee
Navigators
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Coverage Continuum in 2014
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3
4
* Federal Basic Health Plan Option for individuals with incomes between 138% and 200% of the FPL will not be available in 2014.
*
To‐Be Landscape: Continuous Coverage
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SSI Presumptive
Medical Care Services Program
Basic Health Plan
ADATSA
Involuntary Treatment Act
Psych. Indigent Inpatient Program
Take Charge Family Planning
Family Planning Extension
CHIP
Medicaid Standard
Medicaid Benchmark
CHIP
Medicaid Standard
QHP with Subsidy
Note: Transition options to be addressed by State Legislature.
QHP without Subsidy
Post Implementation of the Affordable Care Act (ACA): Subsidized Coverage Landscape in Washington
78250
344
0
200
400
600
800
1000
1200
Current Enrollees Currently Eligiblebut Not Enrolled
Newly Eligible Eligible forSubsidies in the
Exchange
Currently Enrolled (Medicaid)Currently Enrolled (CHIP)Total EligibleLikely to Take Up
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344
Individu
als (in
thou
sand
s)
Note: Analysis forecast assumes full take up rate and the ACA was in effect in 2011. **Includes individuals who have access to other coverage (e.g., employer sponsored insurance). Sources: The ACA Medicaid Expansion in Washington, Health Policy Center, Urban Institute (May 2012); The ACA Basic Health Program in Washington State, Health Policy Center, Urban Institute (May 2012) ; Milliman Market Analysis; ‘and Washington Health Care Authority for Medicaid/CHIP enrollment.
2012
1.16 million current enrollees
2014
545,000currently eligible but not enrolled** 494,000
newly eligible
532,000eligible for subsidies
Post Implementation of the ACA: Remaining Uninsured
▪ Undocumented immigrants
▪ Individuals exempt from the mandate who choose to not be insured (e.g., because coverage not affordable)
▪ Individuals subject to the mandate who do not enroll (and are therefore subject to the penalty)
▪ Individuals who are eligible for Medicaid but do not enroll
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• 9 Issuers• 57 QHPs• up to 229 plans, including cost‐sharing variations
• No Platinum Plans
Gold
• 9 Issuers• 14 Plans• 8 PPO• 4 HMO• 2 Unspecified
Silver
• 9 Issuers• 22 Plans• 9 PPO• 2 PPO HSA• 8 HMO• 1 HMO HSA• 2 Unspecified
Bronze
• 9 Issuers• 17 Plans• 6 PPO• 4 PPO HSA• 4 HMO• 1 HMO HSA• 1 Unspecified HSA
• 1 Unspecified
Catastrophic
• 4 Issuers• 4 Plans• 1 PPO• 2 HMO• 1 Unspecified
*Preliminary View ofIndividual QHP Market
*Data as of 4/1/13, submitted to WAHBE as proposed plans
Exchange Functions
Apply the Essential Health Benefit Plan Levels established by Essential Health Benefits
QHP’s must include items and services within at least the following 10 categories: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including
behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management,
and Pediatric services, including oral and vision care
www.wahbexchange.org
Includes information about:
▪ Exchange Board
▪ Legislation and grants
▪ Policy discussion
▪ TAC and stakeholder involvement
▪ IT systems development
▪ HHS guidance
▪ Listserv registration
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More on the Exchange