Washington  Health  Benefit  Exchange  

AICP  NORTHWEST  CHAPTER  2013  E-­‐DAY  MAy  14,  2013  

Joan  Altman,  JD,  MPH  Senior  Policy  Analyst  

 

Today’s Agenda

▪  Impact  of  the  Affordable  Care  Act  (ACA)    

▪ Building  the  Exchange      ▪ Key  challenges  and  the  future    

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Impact of the Affordable Care Act ▪ Changes to private insurance, including… o Young adults on parents’ policies up to age 26 o Prohibit annual and lifetime monetary caps o Minimum spending on medical care (medical loss ratio)

▪ Expands coverage o Individual Mandate – Minimum Essential Coverage o Expands Medicaid to 138%* of FPL o Large employer responsibility requirement o Exchanges for individuals and small businesses, with

premium tax credits and cost sharing reductions

*ACA  133%=138%  due  to  across  the  board  income  disregards  

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First, some Exchange Basics ▪  Individuals  >138%  of  FPL  and  small  groups  (1-­‐50)    

▪  Tax  credits  available  for  individuals  138%-­‐400%    of  FPL  ▪  Cost  sharing  reducXons  available  for  <250%  FPL    ▪  10  EssenXal  Health  Benefits  ▪ Qualified  Health  Plans  and  Qualified  Dental  Plans    

▪ Metallic  Xers  of  actuarial  value  (Bronze  =  60%;  Silver  =  70%;  Gold  =  80%;  PlaXnum  =  90%)    

▪  Apples-­‐to-­‐apples  comparisons  for  consumers,  one-­‐stop  shop  

▪  Navigators,  in-­‐person  assisters,  agents/brokers,  call  center

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Status of Exchanges

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•  18  Declared  State-­‐based  Exchanges  

•  7  Planning  for  Partnership  Exchange  

•  26  Default  to  Federal  Exchange  

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 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 certified by HHS •  Additional legislative action

taken as needed •  Open Enrollment

begins (October 1)

2011

2012 2013

2014 •  Coverage purchased in the

Exchange begins •  Open enrollment

ends March 31. •  Open enrollment for

2015 coverage begins in Oct.

Governance        Eleven  member,  bi-­‐par/san  board  assumed  authority  on  March  15,  2012    

Margaret  Stanley  –  Chair,  ReXred  ExecuXve  Director,  Puget  Sound  Health  Alliance  

Steve  Appel  –  Farmer,  Past  President  of  the  Washington  Farm  Bureau  

William  Baldwin  –  Partner,  The  Partners  Group  

Donald  Conant  –  General  Manager,  Valley  Nut  &  Bolt,  Assistant  Professor  

Doug  Conrad  –  Professor,  University  of  Washington  

Melanie  CurGce  –  Partner,  Stoel  Rives  

Ben  Danielson  –  Medical  Director,  Odessa  Brown  

Phil  Dyer  –  Senior  VP,  Kibble  &  PrenXce,  and  Former  Legislator  

Teresa  Mosqueda  –  LegislaXve  &  Policy  Director,  Washington  Labor  Council  

*Mike  Kreidler  –  Insurance  Commissioner  

*Dorothy  Frost  Teeter  –  HCA  Director  

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*  non  voXng,  ex  officio  

THE EXCHANGE AS A BUSINESS

Below  the  Surface    §  Develop  and  Host  Technical  Infrastructure  §  Eligibility  DeterminaXon  and  Tax  Credits  §  Review  and  CerXfy  Qualified  Health  Plans  §  Aggregate  Plan  Premiums  §  Manage  and  Train  Customer  Support  §  Monitor  Navigator  Grantees  §  Implement  Program  Integrity  §  Oversee  Eligibility  Appeals  §  Establish  Quality  RaXng  System    

Above  the  Surface      

§     §  MarkeXng  &  Outreach  (  e.g.  AdverXsing)  §  Customer  Support  (e.g.  Navigators,  Call    Center)  

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QHP  Logo  

Family Applying for Coverage Online

▪ Browse  anonymously    

▪ Apply      ▪ Provide  household  income  informaXon    

▪ Review  eligibility  results    ▪  Select  a  health  plan  ▪  Submit  payment

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QHP  Logo  

QHP  Logo  

FILTER  

SORT  

Projected Exchange Member Enrollment (2014 – 2017 Year End)

Membership Growth: “New” Members

WASHINGTON STATE POPULATION IN 2010 BY EXPECTED COVERAGE CATEGORY

EXCLUDES MEDICARE & RETIREE COVERAGE  

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WASHINGTON STATE POPULATION IN 2017 BY EXPECTED COVERAGE CATEGORY

EXCLUDES MEDICARE & RETIREE COVERAGE

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Exchange Revenue Generation – 2015 (Based On 2015 Enrollment Forecast = 343,750)

 

New  Revenue  from  Exchange  Health  Plan  Premiums  ü $1.3  billion    

New  State  Premium  Tax  Revenue  (2%)  ü   $26  million  

Advanced  Premium  Tax  Credit  for  Individuals  ü $520  million  -­‐  $650  million    

ReducXon  in  EsXmated  $1  Billion  in  Uncompensated  Care  ü   Hidden  cost:  $1,017  per  insured  family,  $368  individual  

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Key Challenges

▪  Tight timeline – Oct. 1, 2013 o Federal dependencies and

guidance o  IT flight path – scope, schedule

and budget

▪ Delivery environment o Critical inter-agency

interdependencies

▪ Managing expectations o Options deferred to 2.0 o Complex authorizing

environment

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Recent Federal Guidance ▪ March  1,  2013,  HHS  NoXce  of  Benefit  and  Payment  Parameters  for  2014  

▪ March  1,  2013:  Final  Rule  on  Establishment  of  the  MulX-­‐State  Plan  Program  for  the  Affordable  Insurance  Exchanges  

▪  February  22,  2013,  Final  Rule  on  2014  Health  Insurance  Market  Reforms  

▪  February  20,  2013  Final  Rule  on  EssenXal  Health  Benefits  

▪  January  30,  2013  Final  IRS  Rule  on  Health  Insurance  Premium  Tax  Credit  

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What to look for

▪  In-Person Assisters and Navigators ▪ Exchange Financing/Sustainability

•  ESHB  1947  currently  in  Ways  and  Means  •  Current  budget  appropriaXon  (House  version)  is  conXngent  upon  passage  of  HB  1947

§ System  tesXng  to  begin,  first  with  other  systems  (integraXon  tesXng),  then  user  tesXng  

§ MarkeXng,  outreach  to  ramp  up    

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h^p://wahbexchange.org/  

Includes  informaGon  about:  

▪  Exchange  Board  ▪  LegislaXon  and  grants  ▪  Policy  discussion  ▪  TAC  and  stakeholder  involvement  

▪  IT  systems  development  

▪  HHS  guidance  ▪  Listserv  registraXon  ▪  info@wahbexchange.org  

 

 

 

 

 

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More on the Exchange

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Washington Healthplanfinder Vision:  Redefining  People's  Experience  with  Health  Care  

Mission:  Radically  improving  how  Washingtonian’s  secure  health  insurance  through  

▪ innovaXve  and  pracXcal  soluXons    ▪ easy-­‐to-­‐use  customer  experience    

▪ our  values  of  integrity,  respect,  equity  and  transparency    ▪ providing  undeniable  value  to  the  healthcare  community  (paXents,  providers,  plans)    

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Exchange Governance Structure Who  is  represented?  

▪  Employee  benefits  specialists  ▪  Health  care  finance  specialists  

and  economists  ▪  Health  consumer  advocates  ▪  Small  business  representaXves  ▪  Administrators  from  public  and  

private  health  care  

▪  Consumer  advocates  ▪  Health  insurance  carriers  ▪  Health  insurance  brokers  ▪  Health  care  providers  ▪  Tribal  representaXves    

▪  Technical  experts    

▪  Consumers  ▪  Consumer  advocates  ▪  Health  insurance  carriers  

Individual vs. SHOP Exchange

Individual  Exchange  

- Individuals  who  are  not  on  public  or  employer  sponsored  plans      

SHOP Exchange  

- Small  businesses  with  up  to  50  employees  

- Access  to  QHPs,  federal  subsidies  through  APTC  and    CSR,  and  referrals  to  alternaXve  opXons  (e.g.,  CHIP)  

- Employee  access  to  employer  sponsored  plans  with  increased  choice  - Employer  ability  to  define  contribuXons  and  access  to  small  business  tax  credits  

- IniXal  open  enrollment  is  open  to  all  on  October  1,  2013  with  some  special  enrollment  periods  

- Rolling  enrollment  for  employer  groups;  open  and  special  enrollment  periods  for  employees  

Who:  

What:  

When:  

10 Essential Health Benefits 1.  Ambulatory  paXent  services  

2.  Emergency  services  

3.  HospitalizaXon  4. Maternity  and  newborn  care  

5. Mental  health  and  substance  use  disorder  services  

6.  PrescripXon  Drugs  7.  RehabilitaXve  and  habilitaXve  services  and  devices  8.  Laboratory  Services  9.  PreventaXve  and  wellness  services  10. Pediatric  services,  including  oral  and  vision  care  

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QHP Certification Criteria (* = Also A QDP Criteria)

26  Issuer  1.  Be  licensed  and  good  standing  *  2.  Pay  user  fees,  if  assessed  on  QHPs*  3.  Comply  with  risk  adjustment  program  (but,  monitored  by  OIC  ongoing)  4.  Comply  with  market  rules  (e.g.,  offer  at  gold  and  silver  level)  5.  Comply  with  non-­‐discriminaXon  rules*  6.  Achieve  accreditaXon  with  a  naXonal  organizaXon  

Product  7.  Meet  markeXng  requirements,  if  established  by  HBE*  8.  Meet  network  adequacy  (which  includes  essenXal  community  

providers)*  9.  Provide  or  parXcipate  in  providing  a  health  care  provider  directory*  10.  Implement  a  quality  improvement  strategy  

QHP Certification Criteria (* = Also A QDP Criteria)

27  Product  (cont.)  11.  Submit  health  plan  data  so  it  can  be  used  in  a  naXonal  standard  format*  12.  ParXcipate  in  quality  measures  13.  Use  the  naXonal  standard  enrollment  form  14.  Use  hospital  paXent  safety  contracts  15.  If  offered,  integrate  Direct  Primary  Care  Medical  Home  into  QHP  

Plan  16.  Comply  with  essenXal  health  benefits*,  limits  on  cost  sharing*,  metal  

levels  17.  Comply  with  service  area  standards  for  a  QHP  (e.g.,  county,  zip  code)  and  

submit  rates  for  a  plan  year*  18.  Submit  and  post  jusXficaXons  for  premium  increases  19.  Submit  health  plan  benefits,  cost-­‐sharing,  and  premium  rates  data  to  

display  on  web  pages  for  consumer  shopping*  

 

PLAN REVIEW AND CERTIFICATION

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4/1/13  -­‐-­‐  Issuer  QHP  Submission  Form  Due  

4/1/13  -­‐-­‐    OIC  Regulatory  Review  Process  and  QHP  CerGficaGon  Process  Begins  

7/19/13  -­‐-­‐    HBE  Issuer  ParGcipaGon  Agreement  Due    

7/24/13  &  8/21/13  -­‐-­‐    HBE  Board  MeeGngs  to  finalize  QHP  CerGficaGon