Whi tWashington HlthH ealth BfitB enefit EhE xchange · 2014. 10. 22. · Hiroshi Nakano, Former Board Chair Int’l Community Health Svcs, Administrator, NeoSpine Teresa MdMosqueda,

1 – Washington Health Benefit Exchange UpdatePhil Dyer

October 22, 2014

2014 WSMGMA Payer Forum 1

W hi t H lth B fit E hWashington Health Benefit Exchange

WA MGMAOctober 2014October 2014

Phil DyerBoard Member


October 22, 2014


DISCLAIMERDISCLAIMER;The views and information expressed are my personal opinions and perspectives andmy personal opinions and perspectives and do not represent the official position of the State of Washington or the Washington H lth B fit E h B d St ffHealth Benefit Exchange Board or Staff.


October 22, 2014


The Exchange Board Chair: Ron Sims, Former King County Executive, Former Deputy Secretary for the U.S. , g y , p y y

Department of Housing and Urban Development.

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

Bill Hinkle, Former Legislator

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

Hiroshi Nakano, Former Board Chair Int’l Community Health Svcs, Administrator, NeoSpine

T M d L i l ti d P li Di t f th W hi t St t L b C il d 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 , g


October 22, 2014


Exchange Committee Structure

Exchange Board

Exchange Committee Structure

Policy Committee

Operations Committee

AdvisoryCommittee

Agents & BrokersTAC

Dental TAC

Health Equity TAC

NavigatorTAC

SHOPTAC

Workgroups


October 22, 2014



October 22, 2014


Update/Overview of the Washington Health Benefit ExchangeHealth Benefit Exchange

Up and RunningThe Washington Health Benefit Exchange is a new health insurance marketplace that enables millions of Washingtonians to compare plans side‐by‐side and gain access to financial help to lower the cost of monthly premiums and co‐pays. In its first year, the Exchange changed the health insurance purchasing landscape by:

► Providing real‐time eligibility determination for Medicaid and private coverage

► Supporting a robust customer support network that includes a call center, Navigator program, and broker and agent support team to help people enroll

► Building an efficient marketplace that promotes carrier competition on price and coverage options

► Offering online tools that help customers make informed choices about their health iinsurance


October 22, 2014


Building The Exchange

• Board begins governing authorityESSHB 2319 passed

• Exchange must be certified by HHS• Additional legislative action

taken as needed

20122013

• ESSHB 2319 passed • Deloitte Consulting, LLP, signs on as

system integrator• Exchange names first CEO and

moves into new building

• Open Enrollment begins (October 1)

2011 2014C h d i th• HCA receives one-year

$22.9 million grant to design and develop Exchange

• SSB 5445 passed creating E change as “p blic

• Washington becomes second Level 2 establishment grant recipient, $128 million

• Exchange moves onto own payroll and accounting systems

• Coverage purchased in the Exchange begins

• Open enrollment ends March 31.

• Year 2Exchange as “public private partnership”

• Governor names Exchange Board members

accounting systems• Sustainability plan

submitted to Legislature• WA HBE receives

conditional approval from HHS/CCIIO to operate the

Year 2 open enrollment -NOVEMBE

7

pstate exchange NOVEMBE

R 15, 2014


October 22, 2014


Exchange FunctionsDetermining 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,

li d li istreamlined 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 Program


October 22, 2014


Exchange FunctionsExchanges to build partnerships with entities known as “Navigators” who will reach out to employers and employees, consumers, and self‐employed individuals to: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 g q p

Provide referrals to an applicable consumer assistance program or ombudsman in the case of grievances, complaints, or questions regarding health plans or coverage

P id i f ti i th t i lt ll dProvide information in a manner that is culturally and linguistically appropriate


October 22, 2014


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October 22, 2014



October 22, 2014


Affordable Care Act TerminologyIllustration

Issuer/Carrier Issuer

Product Product

/

Product/Metallic Product 1Product

2

QHP’s/Plans Plan 1 Plan 2 Plan 3 Plan 4

12


October 22, 2014


Exchange FunctionsApply the Essential Health Benefit Plan Levels

established by Essential Health Benefits

QHP’ t i l d it d i ithi t l t thQHP’s must include items and services within at least the following 10 categories: Ambulatory patient servicesAmbulatory patient services Emergency servicesEmergency services HospitalizationHospitalization Maternity and newborn careMaternity and newborn care Mental health and substance use disorder services, including Mental health and substance use disorder services, including

behavioral health treatmentbehavioral health treatment Prescription drugsPrescription drugs Rehabilitative and habilitative services and devicesRehabilitative and habilitative services and devices Laboratory servicesLaboratory services Preventive and wellness services and chronic disease management, Preventive and wellness services and chronic disease management,

andand Pediatric services, including oral and vision carePediatric services, including oral and vision care


October 22, 2014


The “Metallics”The Metallics

Four Levels of Benefits BronzeSilverGoldo d

Platinum


October 22, 2014


Coverage Continuum in 2014

3

*4

* Federal Basic Health Plan Option for individuals with incomes between 138% and 200% of

15

the FPL will not be available in 2014.


October 22, 2014


Washington State QHP Issuers Per CountyQHP Issuers Per County


October 22, 2014


WA HealthPlanFinderEconomic Value to WAEconomic Value to WA

•The state has realized more than $290 million in federal tax credits and offsets to hospital and doctors’ visits

•Hospitals across the state have seen their charity care drop by 30% or nearly $154 Million

•Nation’s 4th largest drop in percentage of uninsured, 16.8% to 10.7%


October 22, 2014


First Open Enrollment Period: Statewide ImpactStatewide Impact

I it fi t f ti th 1 2 illi W hi t i i t lIn its first year of operations, more than 1.2 million Washingtonians – approximately 1 in 6 Washington residents – have obtained or renewed their health coverage through the Washington Healthplanfinder.

► Enrollment numbers exceeded expectations for both the private and public► Enrollment numbers exceeded expectations for both the private and public insurance markets

► Customers have received more than $250 million to help pay for premiums as well as over $40 million to reduce the cost of hospital and provider visitswell as over $40 million to reduce the cost of hospital and provider visits

► OIC reports more than 370,000 people have health insurance today who were previously uninsured


October 22, 2014


The Current MarketplaceThe Current MarketplaceMARKET %

Employer Direct Purchase Medicaid Medicare Military Uninsured

4%16%

45%14%

9%

14%

9%


October 22, 2014


Total Medicaid (MAGI)1 114 800 0001,114,800,000 (July 2014)

600 000

Medicaid MAGI Enrollments

200,000300,000400,000500,000600,000

M di id MAGI0

100,000 Medicaid MAGI Enrollments

•New MAGI Medicaid = 326,447•Medicaid previously eligible not enrolled = 171 451Medicaid previously eligible not enrolled = 171,451•Medicaid Renewals = 516,539


October 22, 2014


Washington HealthPlanFinder

Enrollment1,200,000,000

800,000,000

1,000,000,000

400,000,000

600,000,000

Total Medicaid = 1,114,800,000l

0

200,000,000

Total QHP = 164,062,000

0Qualified Health Plans Medicaid


October 22, 2014


Enrollment by Typey yp

EnrollmentEnrollment

14%

QHP

Medicaid

14%

86%Medicaid


October 22, 2014


QHP EnrollmentQHP Enrollment

160,000

180,000

100 000

120,000

140,000

60,000

80,000

100,000

0

20,000

40,000

0QHP Subsidized No Subsidy


October 22, 2014


Enrollment By Age [VALUE]%65 & Older 1,107

17%

22%

32%

35‐44

45‐54

55‐64

33,456

48,330

25,349

4%

[VALUE]%

16%


October 22, 2014


Enrollment By Metallic

54

36

Sliver

Bronze

82,215

57,150

10

0 10 20 30 40 50 60

Gold 13,242

SliverBronze Gold

54%36% 10%


October 22, 2014


2015 Submission OverviewIndividual Market

10 Issuers |82 Individual QHPs |23 renewed / 59 new

Platinum Gold

10 I

Silver

10 I

Bronze

10 I

Catastrophic

• 1 Issuer• 5 Plans• 0 Renewals• 5 New

• 10 Issuers• 18 Plans• 6 Renewals• 12 New

• 10 Issuers• 29 Plans• 8 Renewals• 21 New

• 10 Issuers • 27 Plans• 8 Renewals• 19 New

• 3 Issuers • 3 Plans• 1 Renewal • 2 New5 New • 2 New


October 22, 2014


Breakdown of 2015 Exchange Plan Offerings

Individual QHP Market – Issuers per County

Individual Market 2014: 8 issuers, 46 plans2015: 10 issuers, 90 plans (8

2014

MSP)New: More choice

Healthplanfinder Business/SHOP2014: 1 Issuer 5 plans2014: 1 Issuer, 5 plans 2015: 2 Issuers, 23 plans

New: Statewide market

Individual Pediatric Dental Market

2015

2014: 5 Issuers, 5 Plans 2015: 5 issuers, 6 plans

New: High-level plans (85% AV)


October 22, 2014


Post Implementation of the ACA: Remaining UninsuredRemaining Uninsured

▪ Undocumented immigrants

▪ Individuals exempt from the mandate who choose to not be insured (e.g., because coverage not affordable)coverage not affordable)

▪ Individuals subject to the mandate who do not enroll (and are therefore subject to the

l )penalty)

▪ Individuals who are eligible for Medicaid but do not enrollbut do not enroll

28


October 22, 2014


Exchange Value – Specific Functions

I. Issuers of QHPs

• Marketing & Outreach• Eligibility Determination for tax

credits• Enrollment• Premium Aggregation

• Customer Service• Enrollment reconciliation with

HHS• New Membership opportunity –

previously uninsured

II H l h C

e u gg egat o

• Easy plan comparison and purchase of health insurance

p e ous y u su ed

• Supporting use of innovative product designs and payment

II. Health Care Market

• Reporting of cost/quality metrics

• Awareness of need for health insurance

methodologies• Expanded access to health

insurance coverage• Reduced charity care

III. Public and State

• Appeals of eligibility determinations and individual responsibility

• Information on health insurance

• Trustworthy source of health care reform information

• Broad‐based Public Information • Other impacts of ACA

29

carriers


October 22, 2014


“No One Ever Washes A Rental Car”


October 22, 2014


Out of Pocket Maximum (OOPM)And Deductible RangesAnd Deductible Ranges

By Metallic▪ Platinum

OOPM $2 500▪ OOPM $2,500

▪ Deductible $ 250.00

▪ Gold

▪ OOPM $ 3,300 ‐ $6,350

▪ Deductible $500‐$1,000

▪ Silver

▪ OOPM $1,250 ‐ $6,600

▪ Deductible $1 500 $3 000▪ Deductible $1,500 ‐ $3,000

▪ Bronze

▪ OOPM $6,0000 ‐ $6,600

▪ Deductible $3,750 ‐ $6,500


October 22, 2014


Unable to Meet the Deductible or the D tDoctor

By ABBY GOODNOUGH and ROBERT PEARNew York Times, OCT. 17, 2014

Patricia Wanderlich got insurance through the Affordable Care Act this year, and with good reason: She suffered a brain h h i 2011 di k i h i l i ihemorrhage in 2011, spending weeks in a hospital intensive care unit, and has a second, smaller aneurysm that needs monitoring.

But her new plan has a $6,000 annual deductible, meaning that Ms. Wanderlich, who works part time at a landscaping company outside Chicago, has to pay for most of her medical services up to that amount. She is skipping this year’s brain scan and hoping for the bestfor the best.


October 22, 2014


P id l i i lProvider plans price more aggressively on insurance exchangesBy Paul DemkoBy Paul Demko

Posted: August 23, 2014 - 12:01 am ET

C fWestern Health Advantage decided to enter California's individual insurance exchange last year even though it previously had offered health plans almost exclusively in the small- and large-group markets.


October 22, 2014


Hospitals ask patients to pay upfrontBy Tami LuhbyBy Tami LuhbySeptember 29, 2014: 2:22 PM ET

Is Obamacare second-rate insurance?NEW YORK (CNNMoney)

Get ready to whip out your credit card before you are wheeled into the operating room or undergo an MRI.Hospitals are increasingly asking patients to pay for procedures either upfront or before they are discharged. That's because Americans are shouldering a greater portion of their health care bills, and medical centers don't want to get stuck with patients that can't pay.


October 22, 2014


More PatientsNot enough Providers?

A W it Ti (PCP A i t t)Average Wait Time (PCP Appointment) prior to the Connector’;14.5 Days

Average Wait Time following implementation of ‘Connector’ and expansion/reduction of uninsured's;

47 Days


October 22, 2014


Payer Calls for More Primary Care Docs, Team CareJohn Commins, for HealthLeaders Media , October 1, 2014

Despite a projected s rge in primar care isits as aDespite a projected surge in primary care visits as a result of coverage expansion, only one in six recent medical school graduates say they will pursue primary care as their field of residency, survey data from UnitedHealth shows.


October 22, 2014



October 22, 2014


Physician (PCP) Shortage ‐ should we be concerned?Sep 25 2014

According to a study conducted by the American Association of Medical Colleges, the United States is facing a shortfall of, roughly, more than 150,000 doctors over the next 15 years and out of that shortfall more than a third of it will be in the area of Primary

hCare Physicians.


October 22, 2014


Exchange Functions

SMALL BUSINESS HEALTH OPTIONS (SHOP)

• Exchanges will operate a Small Business Health Options Program (SHOP) SHOP ill ll l t h th l l f(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 insurerstheir 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

S i i 2014 ll l h i h h SHOP• 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 premiumemployees coverage, and pay at least 50% of the premium.


October 22, 2014


SHOP in 2015 Plan Year

▪ 2014 Kaiser Permanente – Clark & Cowlitz counties ▪ 5 plans▪ Results to date:

▪ 11 enrolled groupsg p

▪ 40 total enrolled participants (employees and dependents)

▪ 2015 Kaiser Permanente – Clark & Cowlitz counties ▪ 9 plans

Moda Health – statewide▪ 14 plans


October 22, 2014


2015 Plan OverviewHealthplanfinder Business

2 QHP Issuers | One carrier in every county, 2 in Clark and CowlitzKaiser Permanente 9 plans; Moda Health 14 plans

Healthplanfinder Business

Gold Silver Bronze

• 5 Plans • 12 Plans • 6 Plans

42


October 22, 2014


New Healthplanfinder Home Page

43


October 22, 2014


Employer Landing Page

44


October 22, 2014


Employer Requirements

There are four general requirements:

▪ Employers of up to 50 employees

▪ Meet minimum participation requirements▪ Up to 3 employees, 100%▪ 4‐50 employees, 75%

▪ Demonstrate an “offer” of coverage to full time employees

▪ Have a business located in Washington State or have employees whose primary worksite is within Washington State ▪ For 2014, Clark & Cowlitz counties only▪ For 2015, statewide

45


October 22, 2014


Update/Overview of the Washington Health Benefit Exchangeg

Funding Model

The legislature has identified three ongoing sources for operationally funding the Exchange. To maintain its current service level, the Exchange estimates that it would need an additional $8.8 million for the biennium.

► The current 2% premium tax paid by commercial health insurance issuers participating in the ► % p p y p p gExchange

► An Exchange carrier assessment in the form of a per member per month payment

►Medicaid cost allocation;Offset of WHPF costs for services being provided by the Exchange on behalf of Medicaid (Washington HealthCare Authority)


October 22, 2014


Exchange Functions and Services

Develop, Host

Website Customer S tHighlight Support, Quality Rating System

g gProducts, Oversee

Navigators

Determine Eligibility

Review & Certify Eligibility,

Tax Credits

Aggregate Premiums

Qualified Plans

Premiums

47


October 22, 2014


www wahbexchange orgMore on the Exchange

www.wahbexchange.org

Includes information about:E h B d▪ Exchange Board

▪ Legislation and grants▪ Policy discussion▪ Policy discussion▪ TAC and stakeholder involvement▪ IT systems developmenty p▪ HHS guidance▪ Listserv registration▪ [email protected]

48


October 22, 2014


QuestionsQuestions


October 22, 2014


Optional Discussion Slides


October 22, 2014


Documents

Whi tWashington HlthH ealth BfitB enefit EhE xchange · 2014. 10. 22. · Hiroshi Nakano, Former Board Chair Int’l Community Health Svcs, Administrator, NeoSpine Teresa MdMosqueda,