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Ernie Sweat CEBS Utah Health Exchange Advisory Board. UTAH HEALTH EXCHANGE 2.0. Overview of the Utah Health Exchange. Limited to small employers (2-50) One of two operational exchanges in the country Market Driven Up to 114 plans available. 4 Participating Carriers. - PowerPoint PPT Presentation
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Ernie Sweat CEBSUtah Health Exchange Advisory Board
Limited to small employers (2-50)
One of two operational exchanges in the country
Market Driven
Up to 114 plans available
Regence Blue Cross Blue Shield
United Healthcare
Select Health
Humana
Regence Blue Cross Blue Shield
United Healthcare
Select Health
Humana
$43/Subscriber$37 to agent$6 to administrators
Added to Raw Rates
Included for all enrollees(even without agent)
Bswift
Health Equity
Prospective Risk Adjustment
Retrospective Risk Adjustment
Employees Complete Universal Applications
Two Carriers in Exchange are Randomly Selected to Underwrite Risk
Rateups are Assigned
If Carriers are Within 30 points, the Average is Assigned
If Outside of 30 Points, a Third Carrier (mediator) is Randomly Selected to Underwrite
Average of two Closest Carriers is Taken to Assign Final Rateup
CAVEAT:Utah State Law Requires Rate Tables Inside
the Exchange to be no Higher than the Underwritten Rate Tables Outside the Exchange
Health Score is Assigned to Each Individual in the Group
Algorithm is used to Average Health Scores for Employees Selecting Each Carrier
Higher Scores Mean a Higher Premium Allotment
All Premium is Pooled and then Allocated to Carriers
New and Terminated Employees are Added to/Subtracted from Algorithm
Average Score is Recalculated Monthly
High Risk Pooling
Claims in Excess of Pooling Level ($75,000) are Identified
Only Claims Between $75,000 and $250,000 are Pooled
75% of Each Qualifying Claim is Calculated
High Risk PoolingExample:
Carrier A: Has a Claim of $100,000 ($25,000 over Pooling Level) $25,000 x 0.75 = $18,750
Carrier B: Has a Claim of $155,000 ($80,000 over Pooling Level) $80,000 x 0.75 = $60,000
Example:Carrier A: $25,000 x 0.75 = $18,750Carrier B: $80,000 x 0.75 = $60,000
Total: $78,750 Tally is Divided by the Membership of
the ExchangeExample: 15,000 Members =
$5.25/Member
Each Carrier Multiplies that Figure by Their Total MembershipExample: Carrier A: 5,000 Members x $5.25 =
$26,250
Amount Determined is Sent to High Risk Pool
High Risk Pool Funds are Distributed to Carriers Who Incurred Large ClaimsCarrier A: $26,250
$18,750
All Dollars from Pool are Distributed to Risk Affected Carriers
Settlement Takes Place 6 Months after Plan Year Zero Sum Game
Access to Multiple Networks
No Minimum Contribution
Both Maternity and Non-Maternity plans may be offered
No restriction on plan options
Exchange 1.0
Bswift
Health Equity
Exchange 2.0
Bswift
Health Equity
eHealthapp
Exchange 1.0Attend Defined Contribution Training SessionMust be Appointed with the majority of the
carriers Exchange 2.0
Attend Updated UHE TrainingAttend Utah Premium Partnership TrainingComplete eHealthapp TrainingMust be appointed with all carriers
Exchange 1.0
Requires employer applicationCumbersome excel spreadsheetBanking data required upfront Employee application via BswiftData unavailable outside Exchange
Exchange 2.0
Broker registers employerNo spreadsheet requiredEmployee application via eHealthappBroker submits group to underwriting
once applications are completeData can be shared with other carriers
as well as Exchange
2.0 AdvantagesBanking data collected AFTER group
selects Exchange as carrierBroker owns the applicationBetter visibility of applicationsAddition of group documents libraryMarketing materials in development
stage
Exchange 1.0
Primary and Secondary Underwriter
Primary Underwriter collects data via Bswift
Secondary Underwriter and Mediator collect data independently
Exchange 2.0
2 primary UnderwritersEach Underwriter receives data
automatically from eHealthappMediator uses same processMuch faster turnaround
Mandated method of employer contribution
Must be determined before employees make elections
Must also choose default plan at this time
Can elect to have excess funds go to HSA account
Health Equity Optum Bank
Employee data from enrollment forms sent to Bswift
Allows employees to have additional time to make selections
Exchange 1.090 daysGenerally earlier than renewal date
Exchange 2.060 daysCan coordinate with renewal dateHolidays may extend this process
Exchange 1.0Handled by Health EquityFunded by broker commission
Exchange 2.0Governed by the Utah Health ExchangeFunded by carriers
Utilizes Calling Tree
Bswift – EnrollmentHealth Equity – BillingeHealthapp – Group EnrollmentUtah Insurance Department – Exchange
OverviewCarriers – Claims and specific questions
Exchange 1.0 Invoice emailed to client on the 5th of prior
month Initial ACH withdrawal takes place on the 8th of
prior monthExchange 2.0
Invoice emailed to client on the 17th of prior month
Initial ACH withdrawal takes place 10 days prior to effective date
Subsequent ACH withdrawals can be moved to late in billing month
Exchange 1.0Received a trend increase
Exchange 2.0Beginning January 1, 2012
PEHP will underwrite Each group rated separately Will utilize any available information
RAB still determining a permanent solution Intending to use All Payer Claim Database
Quality and Cost Data on carriers and providers
Utilize Utah Health Information Network
Mine feedback from consumers
Utilize Federal Funds
Grants
Vouchers
Integrate MedicaidPossible training for agents
Add the individual market
Determine underwriting and risk adjustment process
Decide plan designs▪ Likely that these will match the group market
Define the role and training of navigatorsMust they be licensed?Must they carry E&O insurance?Must they be appointed by the carriers?Will the training regimen be different from
that of an agent?Will there truly be a distinction between
navigator and agent?
Addition of the larger employer sector
Integration of 51-99 market
Is there a place for 100+??
Ernie [email protected]