Washington State Health Insurance Exchange

1. Washington StateHealth Insurance Exchange Phil Dyer Board Member

2. 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 State Health Insurance Exchange Board or Staff.

3. The WA Health Insurance 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.

4. The WA 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: MaryAnne Lindeblad, Director of the Health Care Authority • Ex-Officio: Mike Kreidler, Washington State Insurance Commissioner

5. WA 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.

6. WA Exchange Major Committees • Operations • Chair, Melanie Curtice • Steve Appel • Bill Baldwin • Don Conant • Margaret Stanley • Policy • Chair, Teresa Mosqueda • Doug Conrad • Ben Danielson • Phil Dyer • Margaret Stanley

7. Exchange Board Advisory Committee May 16, 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

8. 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 • · Pam Cowley – Tacoma-Pierce County Health Department • · 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 • 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.

9. 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

10. State Action Toward Creating Health Insurance Exchanges As of August 24, 2012

11. Washington is a Leading State in the Process of Securing $178 Million for Exchange Establishment & Medicaid Eligibility Systems

12. Exchange Functions • Certifying health plans as “Qualified Health Plans” to be offered in the exchange. • 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 Plans • 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.

13. Exchange FunctionsConsumer Interactions • 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

14. 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

15. 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 • Easy plan comparison and purchase of health insurance • Reporting of cost/quality metrics • Awareness of need for health insurance • Supporting use of innovative product designs and payment methodologies • Expanded access to health insurance coverage • Reduced charity care II. Health Care Market III. Public and State • Appeals of eligibility determinations and individual responsibility • Information on health insurance carriers • Trustworthy source of health care reform information • Broad-based Public Information • Other impacts of ACA

16. Exchange Functions Exchanges 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

17. 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.

18. Coverage Continuum in 2014 3 * 4 * Federal Basic Health Plan Option for individuals with incomes between 138% and 200% of the FPL will not be available in 2014.

19. Medicaid Standard CHIP Medicaid Standard Family Planning Extension Medicaid Benchmark Take Charge Family Planning CHIP Psych. Indigent Inpatient Program Involuntary Treatment Act QHP with Subsidy ADATSA Basic Health Plan To-Be Landscape: Continuous Coverage QHP without Subsidy Medical Care Services Program SSI Presumptive Note: Transition options to be addressed by State Legislature.

20. Post Implementation of the Affordable Care Act (ACA):Subsidized Coverage Landscape in Washington 1.16 million current enrollees 545,000currently eligible but not enrolled** 532,000eligible for subsidies 494,000newly eligible Individuals (in thousands) 344 2012 2014 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.

21. 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

22. THE “METALLICS” Four Levels of Benefits Bronze Silver Gold Platinum

23. 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

24. Timeline of Key Tasks: Much Work To Be Done Sept 30 2012: Deadline to select benchmark Essential Health Benefits plan. Dec 31 2014: Exchanges must be self-sustaining. Oct 1 2013: Open enrollment begins. Jan 1 2014: Exchange goes live. Nov 16, 2012: Request federal certification for Exchange operations. July 1 2013: Finalize QHP contracts. Aug 15, 2012: First of ten new opportunities to apply for Exchange grants Jan 1 2013: • Receive conditional or full exchange certification from Secretary. • QHP solicitation bids due. • Initiate marketing & outreach campaign. • Launch assisters training program. Nov 2014: Last Exchange Establishment application deadline. October 2012: Complete business rules and workflow for all eligibility & enrollment operations.

25. To Learn More About the Exchange • Contact: http://www.hca.wa.gov/hbe • Includes information about: • Exchange Board • Legislation and grants • Policy discussion • TAC and stakeholder involvement • IT systems development • HHS guidance • Listserv registration

26. Questions