state insurance exchange & individual plans presented by d. mark baker, director of healthcare...
TRANSCRIPT
State Insurance Exchange & Individual PlansPresented by D. Mark Baker, Director of Healthcare Access, Lifelong
wahealthplanfinder
• The wahealthplanfinder is administered by the Washington Health Benefit Exchange
•Washington developed its own ‘state-based’ exchange▫Still connects with Federal hub
Homeland security IRS
• Joint private public entity▫Funding continues to be a concern
•OIC role▫Regulate carriers, advocates for consumers, approve
plans, and approves rates
Washington Health Benefit Exchange
•Washington Health Benefit Exchange created a sponsorship program for third party payers▫Based on the existing navigator program▫Allows ‘sponsorship representative’ to see a
client/patient’s account and make changes•The Exchange created a premium aggregation
process that the board voted to discontinue▫EHIP is already paying most carriers directly to
combat the payment issues with premium aggregation
Plans offered in the Exchange
2014 2015Carriers 8
Platinum 0
Gold 10
Silver 17
Bronze 12
Catastrophic 2
Total 41
Carriers 10
Platinum 5
Gold 22
Silver 53
Bronze 29
Catastrophic 2
Total 111
2016 Plan Applications (total)
Platinum 17
Gold 57
Silver 99
Bronze 70
Catastrophic 3
Total 246
• 58 of the plan applications below are offered outside of the Exchange• 188 applications are for plans in the Exchange
2016 Applications
•OIC has received applications from 13 carriers who have filed 188 plans for the Exchange in 2016
•Only 24 plans carry over to 2016•Clients/patients need to be aware that several
carriers have discontinued old plans and only offer new plans
•Five new carriers applied this year. Time, Asuris, Regence (of Oregon) United, and Health Alliance
Plan Selection for EHIP
•Working with DOH, EHIP reviews and evaluates plan benefits annually
•Determine the most cost effective plans based on Rx coverage and other factors
• In general, EHIP can pay for Silver, Gold, and Platinum plans on the Exchange
•Also pays for employer sponsored insurance, Medicare Part D, and individual plans outside the Exchange
Exchange Plan Benefits•Rx▫Formularies
The formularies in WA are comprehensive and cover most medications.
▫Tiering for single tab regimens Tier 1 - 13% Tier 2 – 30% Tier 3 – 23% All other Tiers and categories - 30%
•Network adequacy▫Community provider concerns▫Micro networks
Coordination with Ryan White
•45 CFR Part 156▫Requires carriers that offer plans on the Exchange
to accept third party payments from Ryan White providers
▫Debatable if this includes plans outside the Exchange
•Sponsorship▫WA Health Benefit Exchange developed a method
for sponsorship▫EHIP is the largest sponsorship organization
Status
• Issues affecting providers and consumers▫Network adequacy and changes▫High out of pocket maximums▫Prior authorization for drugs and services
PrEP ARV