Washington Health Benefit Exchange - Cascade Care Discussion WSHIP Board Meeting
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Washington Health Benefit Exchange
Cascade Care Discussion
WSHIP Board Meeting
September 25, 2019
Molly Voris, Chief Policy Officer
Washington Health Benefit Exchange
▪ Quasi-governmental entity
▪ Governed by 11-member bipartisan board
▪ Runs Washington Healthplanfinder, which serves one in four
Washingtonians
▪ Single integrated online portal for both MAGI Medicaid (1.5
million) and commercial individual market coverage (200,000)
▪ Offer financial assistance through Medicaid and tax subsidies
for low- and middle-income individuals in private insurance
2
Individual Market Covers 4% of Washingtonians
Office of Financial Management
Forecasting & Research Division
3
4
80% of Individual Market Obtains
Coverage Through Washington Healthplanfinder
Office of Insurance Commissioner: February WA Individual Market Enrollment
5Cascade Care
Response to rising premiums and deductibles and declining
enrollment in the individual market and failure to enact reinsurance
Standard Plans: Goal to make care more accessible by lowering
deductibles, making cost-sharing more transparent, and providing
more services before the deductible.
Public Option Plans: Goal to make more affordable (lower
premium) options available across the state, that also include
additional quality and value requirements
Subsidy Study: Goal to develop and submit a plan for
implementing premium subsidies through Exchange for
individuals up to 500% FPL (report due Nov. 15, 2020)
6Public Option Details: Standard Plans
▪ HBE can establish up to three standardized benefit plans for
each metal level
▪ Starting in PY 2021, QHP carriers must offer at least one gold
and one silver standardized plan, and one bronze
▪ Carriers may also offer non-standardized plans
▪ HBE, with the Office of the Insurance Commissioner, required to
study the impact of offering only standard plans - due to the
Legislature by December 1, 2023
▪ State procured public option plans must incorporate
standardized benefit design
▪ Annually, HBE can update standard benefit design; must
provide notice to carriers by January 31 and include a public
comment period
7Public Option Details: State Procurement
▪ The purchasing authority, in consultation with HBE, required to
selectively contract with carriers to offer bronze, silver, and
gold state procured QHPs for plan year 2021
▪ Contracts require OIC approval and HBE Board certification complete
▪ Carrier participation in the public option is voluntary
▪ Study required on impact of linking carrier and provider participation in
the of publicly procured QHPs, with participation in public employee
programs (due December 1, 2022)
▪ Provider reimbursement rates are tied to Medicare rates,
expected to lower premiums
▪ Carriers must meet additional requirements focused on
increasing quality and value
▪ Including Bree recommendations, care coordination and chronic disease
management
8Public Option Details:
Reimbursement Rate Requirements
▪ Aggregate Cap: Total amount carrier reimburses providers and
facilities cannot exceed 160% of Medicare
▪ Primary Care Physician Floor: Reimbursement for primary care
services (defined by HCA) may not be less than 135% of
Medicare
▪ Rural Floor: Reimbursement for services provided by rural
hospitals (critical access hospitals or sole community hospitals)
may not be less than 101% of Medicare (allowable costs)
9Three Different Types of Health Plans in the Exchange in 2021:
Non-Standard Plans, Standard Plans, and Public Option Plans
Non-Standard Standard Plans Public Option Plans
Plans (Standard Plans Plus)
Offered through the Exchange and eligible for federal tax subsidies
Subject to full regulatory review by OIC, including network adequacy and rate
review requirements
Adheres to 19 Exchange certification criteria for QHPs
Meets federal actuarial value requirements for metal levels
Includes Essential Health Benefits
Uses plan design with deductibles, co-pays, and co-insurance amounts set by
Exchange for each metal level (bronze, silver, gold)
Some services guaranteed to be available before the deductible
Allows consumers to easily compare plans based on premium, network,
quality, and customer service
Procured by HCA (Could result in one or more plans per county)
Required to incorporate Bree Collaborative and Health Technology Assessment
program recommendations
Caps aggregate provider reimbursement at 160% of Medicare
Subject to a floor on reimbursement for primary care services (135% of
Medicare) and reimbursement of rural hospitals (101% of cost)
Requires carriers to offer a bronze plan (in addition to silver and gold)
Carriers required to offer to participate in the Exchange 10Interagency Cascade Care
Implementation Timeline
HBE
June 2019 July 2019 August 2019 September 2019 October 2019 December 2019 January 2020 May 2020 September 2020
First draft of Finalize
Stakeholders Second draft
standard standard Federal AV calculator Board
Standard discuss policy of standard
Begin plan designs plan finalized; standard plan certifies
plan issues using plan designs Public
standard presented to designs designs updated if 2021
stakeholder first draft of presented to Comment
plan stakeholders and necessary plans
group SPs and stakeholders Period
design and present
commences feedback and feedback
feedback for Board
received received
received approval
HCA
June 2019 September 2019 October 2019 December 2019 January 2020 May 2020 September 2020
Review RFP submissions
Develop RFP criteria including value, quality, care management, and negotiate contracts for
HCA procurement process
and reimbursement rate requirements, in consultation with HBE 2021 public option plans
(tentative)
Participate in standard plan stakeholder group
OIC
June 2019 September 2019 October 2019 December 2019 January 2020 March/April 2020 May 2020 September 2020
Publish filing Filing
Review and approve
instructions deadline
2021 plans
(tentative) (tentative)
Participate in standard plan stakeholder groupStandard Plans: Number of Standard Plans at
Each Metal Level
▪ First drafts of standard plans include 2 plans per metal level for
comparison purposes
Gold Silver Bronze
Range: 76%-82% AV Range: 66%-72% AV Range: 56%-65% AV
▪ Two standard gold plans – high actuarial value (81% AV) and low AV (77% AV)
▪ Two silver plans – a 70% AV and a 71% AV
▪ Two bronze plans – high AV (65% AV) and mid AV (62% AV)
▪ Goal was to provide meaningfully different plan designs at each
metal level
▪ Exchange could identify one or more plans at a metal level as
required, and could make some plan designs optional
▪ Expect to finalize 1-2 standard plans per metal level
12Standard Plans: Services Before Deductible
▪ Draft plans place outpatient services before deductible to
drive appropriate utilization to the extent possible, including
office visits and some prescription drugs
▪ Generic and preferred brand drugs before deductible in all
metal levels
▪ Silver plans includes primary care visits, specialist visits,
mental/behavioral health and substance use disorder
outpatient services, urgent care, and physical therapy
▪ Bronze plan includes access to some services before deductible,
including primary care, specialist, and urgent care visits
▪ High-AV gold plan designed for a higher utilizer; e.g., includes
pre-deductible coverage of outpatient surgery and all Rx
categories
13Estimated Premium Impacts of Standard Plans
▪ Wakely estimated how standard plan designs could
impact current plan premiums
▪ Premium impacts across range of current plans
estimated to result in:
▪ Decrease of 9.7% to an increase of 4.8% at the gold level
▪ Decrease of 2.2% to an increase of 1.6% at the silver level
▪ Decrease of 3% to an increase of 5.2% at the bronze level
▪ For context, % of current enrollees in each metal level:
▪ Bronze - 37%
▪ Silver - 51%
▪ Gold - 11%
14Standard Plan
Designs Overview
Notes:
• Alternate 1 includes a per admission co-pay and
Alternate 2 includes a per-day, limit of 5
• Services shaded in blue not subject to the
deductible
15Standard Plan
Designs Overview
Notes: Inpatient Hospital Services is a per day co-pay, 5 days
maximum
Services shaded in blue not subject to the deductible.
16Standard Plan
Designs Overview
Notes:
• Services shaded in blue not subject to the
deductible
• $300 cap on specialty drugs in alternate
plans
17Public Option Implementation Challenges
Defining benchmark
Carrier participation
calculation (160%)
Provider
participation/network Premium impact
adequacy
Ongoing federal and
regulatory activity and
impact on consumers
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