january december 2016 2016 yearly operating report_v7… · an executive summary of...

26
1 WSHIP ADMINISTRATOR’S REPORT January – December 2016 An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment as of 12/31/16: 1,458 (decreased 6% from prior year) Number/percentage sponsored by Third Party: 865 / 59% Non-Medicare Enrolled: 421 / 29% (decreased 15% from prior year) Sponsored by 3 rd Party: 296 / 70% of non-Medicare enrollment Number sponsored by EHIP: 253 Number sponsored by other: 43 Medicare Enrolled: 1,037 / 71% (decreased 2% from prior year) Sponsored by 3 rd Party: 597 / 58% of Medicare enrollment Enrollment YTD: 214 Terminations YTD: 406 Plan Selection: Non-Medicare: PPO – 29%, Standard – 3%, HSA – 1%, Limited A – 0%, Medicare: Basic – 52%, Basic Plus – 15% Age & Gender: Average age: 58 Gender: Female– 36%, Male– 64% ANNUAL ENROLLMENT ACTIVITY (Non-Medicare enrollment is closed): Number of applications received: 282 Number of applications approved: 242 Number of applications pended: 170 Number of applications denied: 28 Primary denial reason: Lack of response to request for missing information Percent of applications submitted by agents: 18% Percent of applications submitted by Third Party: 51% (Kidney Centers only) Terminations in the reporting year: (34% of terminations were due to non-payment) Medicare Terminations: 257 Non-Medicare Terminations: 120

Upload: others

Post on 30-Jul-2020

1 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

1

WSHIP

ADMINISTRATOR’S REPORT

January – December 2016

An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities

YEARLY ENROLLMENT SUMMARY

Total Enrollment as of 12/31/16: 1,458 (decreased 6% from prior year)

Number/percentage sponsored by Third Party: 865 / 59%

Non-Medicare Enrolled: 421 / 29% (decreased 15% from prior year)

Sponsored by 3rd Party: 296 / 70% of non-Medicare enrollment

Number sponsored by EHIP: 253

Number sponsored by other: 43

Medicare Enrolled: 1,037 / 71% (decreased 2% from prior year)

Sponsored by 3rd Party: 597 / 58% of Medicare enrollment

Enrollment YTD: 214 Terminations YTD: 406

Plan Selection:

Non-Medicare: PPO – 29%, Standard – 3%, HSA – 1%, Limited A – 0%,

Medicare: Basic – 52%, Basic Plus – 15%

Age & Gender: Average age: 58 Gender: Female– 36%, Male– 64%

ANNUAL ENROLLMENT ACTIVITY (Non-Medicare enrollment is closed):

Number of applications received: 282

Number of applications approved: 242

Number of applications pended: 170

Number of applications denied: 28

Primary denial reason: Lack of response to request for missing information

Percent of applications submitted by agents: 18%

Percent of applications submitted by Third Party: 51% (Kidney Centers only)

Terminations in the reporting year: (34% of terminations were due to non-payment)

Medicare Terminations: 257

Non-Medicare Terminations: 120

Page 2: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

2

YEARLY CLAIMS EXPENSE

Medical Claims Paid: $25,998,310

Medicare: $9,577,298

Non-Medicare: $16,421,010

Pharmacy Claims Paid: $15,476,969.00

Medicare: $1,233,905

Non-Medicare: $14,243,064

Total Claims Paid: $41,475,280

OTHER YEARLY ACTIVITY

Claims Activity:

Number of claims received: 81,265

Customer Service Telephone Calls and Website Visitors:

Average calls per day: 37

Average website visitors per day: 19

Appeals:

Number of appeals received related to eligibility: 119

First Level (Administrator) 109; Second Level (Grievance Committee) 10

Number of appeals received related to other: 63

First Level (Administrator) 63; Second Level (Grievance Committee) 0

Number of appeals adjudicated in favor of applicant/enrollee: 94

Number of appeals adjudicated and denied: 88

OIC Complaints:

Number of complaints received: 1

Page 3: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Monthly Operations Report

2016 Yearly Operating Report

Page 4: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

1065

2333

2062

25322652

2889 30873266

3447 3397 3578

3923 3862

3675

4022

17371556 1458

Total Enrollment by Calendar Year1999 - 2016

NOTE: This chart depicts total enrollment within WSHIP at year end. In 2016 enrollment decreased 6.3% from 2015. Enrollment increased in 1999 when individual insurance products were no longer available in most Washington counties, and legislation allowed access to the Pool. The Standard Health Questionnaire was utilized from 2000-2013 to determine a threshold for coverage by carriers. The substantial decrease in WSHIP enrollment is due to increased access made available by the Affordable Care Act and the Washington Health Benefit Exchange.

Chart 1

Page 5: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

918 1678 1378 1678 1544 1403 1872

596

0

50

100

150

200

250

300

350

400

450

500

550

600

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Num

ber o

f Enr

olle

es

Non-Medicare Policies in Force2007- 2016

$500 Standard Plan $1,000 Standard Plan $1,500 Standard Plan $500 PPO Plan $1,000 PPO Plan $2,500 PPO Plan $5,000 PPO Plan

NOTE: This chart depicts the change in enrollment by plans. The HSA Qualified PPO Plan and Limited PPO Plans A and B were added in January of 2008 and are not included in this chart. Beginning in 2014, Non-Medicare plans are no longer open to new enrollment if individual plans are offered in all counties.

Chart 2

Page 6: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

160

332

241

332

526

674728

778813 829

408

505

571

505458

347304

276238

208

334

0

100

200

300

400

500

600

700

800

900

1,000

1,100

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Num

ber o

f Enr

olle

es

Medicare Policies in Force2007 - 2016

Basic Plan Basic Plus Plan Plan 2

NOTE: This chart depicts the change in enrollment by Medicare plans. Medicare Part D was introduced in 2006 causing a sharp decrease in WSHIP enrollment in Plan 2 as enrollees switched to either the Basic or Basic Plus plan options which were added in January of 2006. Effective January 2008, Plan 2 enrollees were required to switch to either Basic or Basic Plus plan options. Basic Plus was closed to new enrollment Dec. 31, 2008

Chart 3

Page 7: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

14.3

%

7.6%

31.3

%

7.7%

7.8%

13.6

%

4.8%

12.9

%7.9%

3.0% 3.

7%

6.1%

8.5%

2.1%

4.1%

11.4

%

4.6%

31.3

%

3.1%

12.4

%

4.4%

1.4%

13.8

%

24.3

%

11.8

%

5.6%

29.9

%

20.1

%

3.9%

1.6% 2.6%

34.4

%

18.1

%

19.1

%

2.8%

19.1

%

4.6%

0.7%

1.1%

0

100

200

300

400

500

Non-Payment Death Other Coverage Moved Out ofState

Insured Request Medicare Financial Hardship Loss of 3rd PartyPayor

Num

ber o

f Enr

olle

es

Terminations by Reason(for all 2012 - 2016 terminations)

2012 2013 2014 2015 2016

NOTE: This chart depicts the reasons coverage was terminated for enrollees. "Insured Request" indicates those who did not state a reason for terminating. "Non-Payment" reflects enrollees who did not respond to queries regarding reasons for non-pay.

64.6

%

Chart 4

Page 8: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

HSA Qual PPO Plan Limited PPO A Basic Plan Basic Plus Plan

Age $500 $1,000 $1,500 Age $500 $1,000 $2,500 $5,000 Age $3,000* $1,500* Age0-18 4 0 0 0-18 11 2 0 1 0-18 0 0 0-18 0 019-29 4 0 2 19-29 9 4 5 0 19-29 0 0 19-29 8 030-34 1 0 1 30-34 32 5 1 0 30-34 0 0 30-34 15 135-39 3 0 0 35-39 51 1 2 1 35-39 0 0 35-39 25 040-44 4 0 0 40-44 59 2 4 2 40-44 2 0 40-44 49 345-49 1 1 1 45-49 55 0 9 2 45-49 2 0 45-49 71 450-54 6 2 2 50-54 35 3 5 1 50-54 0 0 50-54 105 1755-59 0 0 0 55-59 20 1 8 3 55-59 4 0 55-59 147 2960-64 1 1 1 60-64 12 4 11 5 60-64 5 0 60-64 180 4265-69 0 0 1 65-69 2 0 0 0 65-69 0 0 65-69 105 3670-74 2 0 0 70-74 1 0 0 0 70-74 0 0 70-74 70 3675-79 0 0 0 75-79 0 0 1 0 75-79 0 0 75-79 29 2280-84 0 0 0 80-84 0 0 0 0 80-84 0 0 80-84 19 1585+ 0 0 0 85+ 0 0 0 0 85+ 0 0 85+ 6 3Total 26 4 8 Total 287 22 46 15 Total 13 0 Total 829 208

* Began enrolling on January 1, 2008.

TOTAL ENROLLMENT: 1,458

Plan & Age Distribution Summary as of December 31, 2016

Standard Plan PPO Plan

Total STD Plan Enrollment= 38 Total PPO Plan Enrollment = 383 Total Medicare Enrollment = 1,037

NOTE: This chart depicts the enrollment of WSHIP by plan within each of the illustrated age bands. The Limited PPO Plan B was closed in May 2014.

26 4 8

287

22 46 15 13

829

208

0100200300400500600700800900

$500Standard

Plan

$1,000Standard

Plan

$1,500Standard

Plan

$500 PPO Plan

$1,000 PPO Plan

$2,500PPOPlan

$5,000PPOPlan

HSAQualified

HDHP

BasicPlan

BasicPlusPlan

Num

ber o

f Enr

olle

es

Chart 5

Page 9: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

0 25 50 75 100 125 150 175 200

0 - 1 Year

1 - 2 Years

2 - 3 Years

3 - 4 Years

4 - 5 Years

5 - 6 Years

6 - 7 Years

7 - 8 Years

8 - 9 Years

9 - 10 Years

10 - 15 Years

15 + Years

# of Enrollees

Time Policyholders Enrolled in WSHIP

Basic Plus Plan Basic Plan HSA Qualified Preferred Preferred Plan Standard Plan

NOTE: This chart depicts the duration of time enrollees with non-Medicare and Medicare polices are enrolled with WSHIP as of December 31, 2016.

Chart 6

Page 10: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

0 25 50 75 100 125 150 175 200

0 - 1 Year

1 - 2 Years

2 - 3 Years

3 - 4 Years

4 - 5 Years

5 - 6 Years

6 - 7 Years

7 - 8 Years

8 - 9 Years

9 - 10 Years

10 - 15 Years

15 + Years

# of Enrollees

Time Enrolled in WSHIPMedicare Policies

Basic Plus Plan Basic Plan

NOTE: This chart depicts the duration of time enrollees with Medicare policies were enrolled with WSHIP as of December 31, 2016. Basic and Basic Plus plans have been available for eight years. However, the activity beyond eight years illustrates enrollees who at one point had Plan 2 coverage and then changed to either the Basic or the Basic Plus plans. As of January 2008, all Plan 2 enrollees were required to either terminate coverage or move to the Basic or the Basic Plus plans.

Chart 7

Page 11: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

0255075

100125150175200225250

AD

AMS

ASO

TIN

BEN

TON

CH

ELA

N

CLA

LLAM

CLA

RK

CO

LUM

BIA

CO

WLI

TZ

DO

UG

LAS

FER

RY

FRA

NKL

IN

GAR

FIEL

D

GR

AN

T

GR

AYS

HA

RBO

R

ISLA

ND

JEFF

ER

SON

KIN

G

KIT

SAP

KIT

TITA

S

KLI

CK

ITA

T

LEW

IS

LIN

CO

LN

MA

SO

N

OKA

NO

GAN

PAC

IFIC

PEN

D O

REI

LLE

PIE

RC

E

SAN

JU

AN

SKA

GIT

SN

OH

OM

ISH

SPO

KAN

E

STE

VEN

S

THU

RS

TON

WAH

KIA

KUM

WAL

LA W

ALL

A

WH

ATC

OM

WH

ITM

AN

YAK

IMA

County

2016 Enrollment By CountyN

umbe

r of E

nrol

lees

4471

0.00%

0.01%

0.02%

0.03%

0.04%

0.05%

0.06%

AD

AMS

ASO

TIN

BEN

TON

CH

ELA

N

CLA

LLAM

CLA

RK

CO

LUM

BIA

CO

WLI

TZ

DO

UG

LAS

FER

RY

FRA

NKL

IN

GAR

FIEL

D

GR

AN

T

GR

AYS

ISLA

ND

JEFF

ER

SON

KIN

G

KIT

SAP

KIT

TITA

S

KLI

CK

ITA

T

LEW

IS

LIN

CO

LN

MA

SO

N

OKA

NO

GAN

PAC

IFIC

PEN

D…

PIE

RC

E

SAN

JU

AN

SKA

GIT

SN

OH

OM

ISH

SPO

KAN

E

STE

VEN

S

THU

RS

TON

WAH

KIA

KUM

WAL

LA W

ALL

A

WH

ATC

OM

WH

ITM

AN

YAK

IMAEn

rollm

ent P

erce

nt

County

2016 Enrollment by % of Total County Population0.18%

Chart 8

Page 12: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

$0

$341

$1,658

$3,218

$7,555

$11,754

$20,148

$36,592

$60,667

$85,628

$121,265

$407,953

$0

$418

$1,714

$3,632

$7,621

$12,090

$18,029

$34,815

$54,147

$82,368

$125,184

$208,652

0 50 100 150 200 250 300 350 400

$0

$1-$1000

$1,001-$2,500

$2,501-$5,000

$5,001-$10,000

$10,001-$15,000

$15,001-$25,000

$25,001-$50,000

$50,001-$75,000

$75,001-$100,000

$100,001-$150,000

> $150,000

Number of Claimants

Distribution of Total Allowed* Medical and Pharmacy Claims 2016

Medicare

Non-Medicare

NOTE: This chart depicts the total allowable charges for all medical and pharmacy claims processed in 2016 for all enrollees. The allowable claim costs have been banded as illustrated below. The average allowed medical and pharmacy cost per member per year (PMPY) is $20,180. At the end of each bar is the total average PMPY cost for the corresponding dollar band. 1.6% of the Non-Medicare enrollees drove 50% of total Non-Medicare costs. 12.5% of the Medicare enrollees drove 50% of total Medicare costs.

* Allowed: The dollar amount after deducting discounts and/or what other insurance has already paid.

Chart 9

Page 13: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

Note: This chart illustrates the loss ratio and expense ratio for the calendar year for all WSHIP plans. Medicare and Non-Medicare totals are reflected in the green bars at the right side of each chart.

0%100%200%300%400%500%600%700%800%900%

1000%1100%1200%1300%1400%

HSAQualified

$500PPO

$1000PPO

$2500PPO

$5000PPO

$500Standard

$1000Standard

$1500Standard

Basic BasicPlus

MedicareTotal

Non-Medicare

Total

2016 Expense Ratio by Plan

0%100%200%300%400%500%600%700%800%900%

1000%1100%1200%1300%1400%

HSAQualified

$500PPO

$1000PPO

$2500PPO

$5000PPO

$500Standard

$1000Standard

$1500Standard

Basic BasicPlus

MedicareTotal

Non-Medicare

Total

2016 Total Loss Ratio by Plan

Chart 10

Page 14: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

NOTE: This chart illustrates medical, pharmacy and total claims paid by plan. Medicare and Non-Medicare totals are reflected in the green bars at the right side of each chart. In 2016, WSHIP paid $26,883,191 in medical claims and $15,636,497 in pharmacy claims, for a total of $42,519,688.

1.3%

14.8%

3.3% 4.0% 1.5%

14.2%

0.1% 1.5%

19.7%

2.9%

22.6%

40.6%

$-

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

$30,000,000

HSAQualified

$500PPO

$1000PPO

$2500PPO

$5000PPO

$500Standard

$1000Standard

$1500Standard

Basic BasicPlus

MedicareTotal

Non-Medicare

Total

2016 Medical Claims Paid by Plan

0.3%

27.3%

3.5% 1.2% 0.0% 1.0% 0.1% 0.4% 0.1%2.8%

36.8%33.9%

$-

$5,000,000

$10,000,000

$15,000,000

$20,000,000

HSAQualified

$500PPO

$1000PPO

$2500PPO

$5000PPO

$500Standard

$1000Standard

$1500Standard

Basic BasicPlus

MedicareTotal

Non-Medicare

Total

2016 Pharmacy Claims Paid by Plan

1.6%

42.0%

6.7% 5.3% 1.5%15.2%

0.2% 1.9%19.8%

5.7%25.5%

74.5%

$-

$10,000,000

$20,000,000

$30,000,000

$40,000,000

$50,000,000

HSAQualified

$500PPO

$1000PPO

$2500PPO

$5000PPO

$500Standard

$1000Standard

$1500Standard

Basic BasicPlus

MedicareTotal

Non-Medicare

Total

2016 Total Claims Paid by Plan

Chart 11

Page 15: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

$-

$5,000

$10,000

$15,000

$20,000

HSAQualified

$500PPO

$1000PPO

$2500PPO

$5000PPO

$500Standard

$1000Standard

$1500Standard

Basic BasicPlus

MedicareTotal

Non-Medicare

Total

2016 Medical Claims Paid Per Member Per Month (PMPM) by Plan

$-

$1,000

$2,000

$3,000

$4,000

HSAQualified

$500PPO

$1000PPO

$2500PPO

$5000PPO

$500Standard

$1000Standard

$1500Standard

Basic BasicPlus

MedicareTotal

Non-Medicare

Total

2016 Pharmacy Claims Paid Per Member Per Month (PMPM) by Plan

$-

$5,000

$10,000

$15,000

$20,000

$25,000

HSAQualified

$500PPO

$1000PPO

$2500PPO

$5000PPO

$500Standard

$1000Standard

$1500Standard

Basic BasicPlus

MedicareTotal

Non-Medicare

Total

2016 Total Paid Claims Per Member Per Month (PMPM) by Plan

Chart 12

Page 16: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

Enrollment Plan CostsMembers Months Total Premiums Total Out-of-Pocket Total Plan Paid Member Costs Plan Costs

Standard Plans 480 738,358$ 45,199$ 7,384,390$ 1,632 15,384$ Preferred Provider Plan 4,558 5,359,417$ 507,597$ 23,614,937$ 1,287$ 5,181$

HSA Qualified Plan 156 130,392$ 62,926$ 660,621$ 1,239$ 4,235$ Total Non-Medicare 5,194 6,228,167 615,721 31,659,948 1,318$ 6,095$

Basic Plus 2,642 1,409,519$ 8,005$ 2,439,169$ 537$ 923$ Basic 9,824 3,428,869$ 15,308$ 8,420,667$ 351$ 857$

Total Medicare 12,466 4,838,388 23,314 10,859,835 390$ 871$ Total All Plans 17,660 11,066,554 639,035 42,519,783 663$ 2,408$

Member Costs PMPMAnnual Totals

2016 Cost Sharing on a Per Member Per Month (PMPM) BasisNOTE: This chart illustrates the cost sharing on a per member per month (PMPM) basis. Enrollees' totals include all out-of-pocket related health plan costs (co-pays, deductibles, coinsurance) in addition to the annual premium.

Chart 13

Page 17: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

2012

2012

2012

2012

2012

2013

2013

2013

2013

2013

2014

2014

2014

2014

2014

2015

2015

2015

2015

201520

16

2016

2016

2016

2016

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Hospital Inpatient Hospital Outpatient Office Outpatient Drugs Other

Perc

ent o

f Tot

al

Distribution of Claim Payments by Place of Service 2012 - 2016NOTE: This chart depicts the annual paid medical and pharmacy claims cost for each place of service as a percent of the total annual cost. "Other" is a total of services not within the defined labels below, such as Ambulance, Community Mental Health Center, Home Health / Hospice, and Substance Abuse Treatment Center.

Chart 14

Page 18: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

$18,000

$20,000

2010 2011 2012 2013 2014 2015 2016

Preferred Provider Plans Standard Plans

NOTE: This chart depicts network discounts for both the Standard and Preferred Provider Plans on a PMPM basis for 2010 through 2016. In 2016, the network savings as a percent of total in-network charges for Standard Plans was 62% and for Preferred Provider Plans was 38.3%. The total combined network savings was 49.7%.

Network Savings on a Per Member Per Month (PMPM) Paid Basis for 2010 - 2016

Chart 15

Page 19: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

Percent of Claims Dollars Paid Percent of Dollars PaidIn-Net Out-of-Net In-Net Out-of-Net In-Net Out-of-Net

PPO Plans 89% 11% 9,398,459$ 945,628$ 91% 9%STD Plans 94% 6% 6,692,995$ 61,727$ 99% 1%

In-Network versus Out-of-Network Utilization 2016

NOTE: This chart illustrates the utilization of in-network providers versus out-of-network providers. For enrollees within the Preferred Provider Plans, 89% of the time they were utilizing an in-network provider which resulted in 91% of the total dollars paid. For enrollees within the Standard plans, 94% of the time they were utlizing an in-network provider which resulted in 99% of the total dollars paid.

Chart 16

Page 20: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

Service Code Analysis 2016 Paid Medical Claims

$0

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

$700,000

$800,000

$900,000

$1,000,000

$1,100,000

$1,200,000

$1,300,000

$1,400,000

$1,500,000

$1,600,000

$1,700,000

$1,800,000

$1,900,000

$2,000,000

NOTE: This chart depicts the total paid medical claims per each service code or benefit category with total charges $100,000 and up. As a percentage of total claims paid, ancillary charges accounted for 53.6% , injections represented 10.2% and diagnostic testing equaled 10%. The top three ancillary charges billed were Ancillary Charges ($13.6 million) Injections ($2.6 million) and Diagnostic Testing ($2.5 million).

Chart 17

Page 21: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 9, 2016

$0.00

$1,000,000.00

$2,000,000.00

$3,000,000.00

$4,000,000.00

$5,000,000.00

$6,000,000.00

Top 10 Ancillary Services 2016

Chart 18

Page 22: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

22%

24%

26%

28%

30%

Perc

ent o

f Tot

al M

edic

al C

laim

s

Major Diagnostic Categories by % of Total Medical Claims Paid in 2016

Total Medicare Non-Medicare

NOTE: This chart depicts the paid medical claims based upon Major Diagnosis Categories for all plans. The % of WSHIP claims billed under the Kidney and Urinary Tract Disease Diagnosis Cateory in 2016 was: non-Medicare - 52.95%, Medicare - 77.80% and Total - 61.56%.

Chart 19

Page 23: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

Provider Name Paid AmountPercent of Total

Medical Claims Paid FCHN Provider? Total Renal Care 3,913,147.50 15.1% YesNorthwest Bethany 2,943,250.57 11.4% YesNorthwest Kidney Centers 1,246,398.29 4.8% YesPuget Sound Blood Center 1,201,729.68 4.6% YesProvidence Health & Services 1,027,136.09 4.0% YesHarborview Medical Center 903,460.53 3.5% YesVirginia Mason Center 640,875.37 2.5% YesThe Regional Hospital for Respiratory & Complex Care 632,850.19 2.4% YesVGM Group Inc 614,267.59 2.4% YesPuget Sound Kidney Centers 574,759.94 2.2% YesKadlec Regional Medical Center 538,437.82 2.1% YesSeattle Childrens Hospital 528,243.31 2.0% YesSt Joseph Medical Center 477,969.18 1.8% YesCentral Washington Hospital 398,633.42 1.5% YesBirth and Family Clinic 395,863.92 1.5% YesUniversity of Washington 390,516.44 1.5% YesProvidence Everett Medical Labs 378,328.88 1.5% YesInland Northwest Renal Care Group 318,363.32 1.2% YesKennewick Public Hospital District 292,647.80 1.1% YesOption Care Enterprises Inc 287,388.47 1.1% YesNorth Spokane Renal Services 279,351.18 1.1% YesProvidence Health & Services 274,480.33 1.1% YesMulticare Health Systems 269,365.32 1.0% YesSwedish Health Services 261,539.35 1.0% YesAssociation of University Physicians 255,971.69 1.0% YesTotal of all other providers 6,843,805$ 73.6%

Top 25 Providers by 2016 Medical Claims PaidNOTE: This chart depicts the top 25 providers in 2016 by medical claims paid. The top 25 providers account for approximately 74% of claim dollars paid in 2016.

Chart 20

Page 24: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

20 Total PPO Plan = 276 597296

893

Third Party Sponsors Members Plan & Age Distribution Summary as of December 31, 2016

Standard Plan PPO Plan HSA Qual PPO Plan Basic Plus Plan

0-18 1 0 0 0-18 0$3,000Age

Basic PlanAge$500 $1,000 $1,500 Age $5000-18

$1,000 $2,500 $5,000 Age1 0 1 0

19-29 3 0 1 19-29 70-18 0 0

19-29 0 719-29 00 2 00 11

35-39 3 0 0 35-39 481

35-39 0 2135-39 030-34 1 30-34 0 30-34

0 0 00 0 30-34 31 0 0

0 0 5845-49 10 391

00 1 40-44 0

45-4940-44

240-44 2 0 0 40-44 57

50-54 4 0 0 50-54 3345-49 1 0 0 45-49 53

50-540 50-54 0 4 8455-59 0 0 0 55-59 19

0 055-59 2 10455-59 20 3 0

65-69 0 0 0 65-69 20

65-69 665-69 060-64 1

0 0 01 0 60-64 9 60-64 40 0

75-79 0 0 0 75-79 00 0 070-74 2 0 0 70-74 10 0 0

1 60-64

80-84 085+ 0 285+ 0

70-74 0 4270-74 075-79 0 1775-79 0

11670

0 0 85+ 00 0 080-84 0 0 0 80-84 00 0 0

NOTE: Third party sponsors accounted for 61.2% of the total WSHIP population. At the end of 2016, EHIP had 253 enrollees, DSHS had 5, and Kidney Organization Sponsors had 607.

TOTAL ENROLLMENT:

Total 17 580Total Standard Plan = Total Medicare =

3 7 3 Total 3Total 18 1 1 Total 260

Total Non-Medicare =

80-84 1 985+ 0

18 1 1

260

3 7 3 3 17

580

0100200300400500600700

$500Standard

Plan

$1000Standard

Plan

$1,500Standard

Plan

$500PPOPlan

$1,000PPOPlan

$1,500PPOPlan

$2,500PPOPlan

HSAQualified

HDHP

BasicPlusPlan

BasicPlan

Num

ber o

f Enr

olle

es

Chart 21

Page 25: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

NOTE: This chart depicts the paid medical and pharmacy claims on a per member per month (PMPM) basis for each of the three primary third party sponsors and how each compares to WSHIP in total. The percentages on each bar graph represent the medical and pharmacy costs of each primary third party sponsor as a percentage of the total WSHIP medical and pharmacy costs. In 2016, third party sponsor claims represent 61% of the total annual claim costs for WSHIP.

11.8%

54.8%

27.6%

51.1%

2.8%

33.3%

0.2%0.4%

0.2%

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

$4,500

Medical Pharmacy Total

EHIP Kidney DSHS Total

2016 Claims Paid Per Member Per Month (PMPM): WSHIP -vs- Third Party Sponsors

300%

486%

152%

384%

0%

100%

200%

300%

400%

500%

600%

EHIP KIDNEY DSHS WSHIP (total)

2016 Loss Ratio: WSHIP -vs- Third Party Payors

Chart 22

Page 26: January December 2016 2016 Yearly Operating Report_V7… · An Executive Summary of Administrator’s Yearly Operating Report and Pool Activities YEARLY ENROLLMENT SUMMARY Total Enrollment

Washington State Health Insurance Pool 2016 Yearly Operating Report March 8, 2017

2014 2015 20169,560 5,952 5,278 Total number of unique visitors

26 16 14 Average daily number of unique visitors

Health Reform

1,003 Medicare Benefits1,508 Contact Us1,694

For Board of Directors

330 Yearly Reports

821 Provider Network

324 Assessment Form

2,918 Medicare Eligibility

WSHIP Web Site Statisticswww.wship.org

2013 through 2016 Comparison

Interesting Facts

Page NameNumber of SessionsTop 10 Pages Most Frequently Accessed

326

Monthly Premiums

575 About WSHIP652

0 100 200 300 400 500 600 700 800 900 1,000 1,100 1,200

11-30 sec

31-60 sec

1-3 min

3-10 min

10-30 min

30+ min

# of Unique Visitors

Average Length of Visit

201620152014

Chart 23