washington health benefit exchange exchange 101 summer 2013 navigator/in-person assister program
TRANSCRIPT
Washington Health Benefit Exchange
Exchange 101Summer 2013
Navigator/In-person Assister Program
Purpose and Objectives
Purpose:
This presentation is to provide an overview of the Washington Health Benefit Exchange.
Objectives:
Upon completion of this presentation you will have an understanding of:▪ Governance Structure▪ Exchange Functions ▪ Preview of the Washington Healthplanfinder
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Exchange 101 Topics
▪ Building the Exchange
▪ Exchange Governance
▪ Functions and Services
▪ Washington Healthplanfinder
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Building The Exchange
• HCA receives one-year grant to design and develop Exchange
• SSB 5445 passed creating Exchange as “public private partnership”
• Governor names Exchange Board members
• Board begins governing Exchange Operations
• Exchange names first CEO and moves into new building
• Washington receives a Level 2 establishment grant
• Sustainability plan submitted to Legislature
• WA HBE receives conditional approval to operate the state exchange
• Exchange must be certified by HHS
•Open Enrollment begins October 1
2011
20122013
2014• Coverage purchased in
the Exchange begins January 1
• Employee benefits specialists• Health care finance specialists
and economists• Health consumer advocates• Small business
representatives• Administrators from public
and private health care
• Consumer advocates• Health insurance carriers• Health insurance brokers• Health care providers• Tribal representatives
• Technical experts
• Consumers• Consumer advocates• Health insurance carriers
Governance Structure
Vision and Mission
Vision: Redefining People's Experience with Health Care
Mission: Radically improving how Washingtonians secure health insurance through
▪Innovative and practical solutions
▪Easy-to-use customer experience
▪Our values of integrity, respect, equity and transparency
▪Providing undeniable value to the healthcare community (patients, providers, plans)
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Individual and Business Exchange
Individual Exchange
‑ Individuals and families who are not covered by an employer provided plan
Business Exchange
‑ Small businesses with up to 50 employees
‑ Access to Medicaid, QHPs, federal subsidies through health insurance tax credits or other cost reductions
‑ Employer ability to define their percentage of contributions and access to small business tax credits
‑ Employee access to employer sponsored plans with increased choice
‑ Initial open enrollment is open to all 10/1/2013-3/31/2014
‑ Application must be submitted by the 23rd of the month for coverage effective the 1st of the following month
‑ Open for enrollment 10/1/2013 for coverage effective 01/01/2014
Who:
What:
When:
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Exchange Functions & Services
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Exchange Functions & Services
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How will people get health care coverage?
Exchange Functions & Services
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Exchange Functions & Services
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Washington Healthplanfinder Homepage
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QHP Logo
Individual Landing Page
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Decision Support Tools
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▪ Sort: Orders plan options
▪ Filter: Displays/hides plan options
▪ Wizard: Questionnaire that applies filters
▪ Search for your Health Care Provider/Hospital
▪ Compare Plans: View up to three plans side-by-side
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QHP Logo
QHP Logo
FILTER
SORT
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QHP Logo
QHP Logo
PLAN WIZARD
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QHP Logo
QHP Logo
HC PROVIDERSEARCH
Exchange Functions & Services
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QUALIFIED HEALTH PLANS
Qualified health plans must:
▪Include the ten essential benefit categories
▪Offer sufficient choice of providers
▪Measure service quality and patient satisfaction
▪Provide accurate, understandable consumer information
▪Be a private health insurance company
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Ten essential Health benefits
1. Ambulatory services 6. Prescription drugs
2. Emergency services 7. Rehabilitative and habilitative services and devices
3. Hospitalization 8. Laboratory services
4. Maternity and newborn care 9. Preventive and wellness services and chronic disease management
5. Mental health and substance use disorder services, including behavioral health treatment
10. Pediatric services, including oral and vision care
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QUALIFIED HEALTH PLANS
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Bronze – covers 60% of actuarial value* of benefits
Silver – covers 70% of actuarial value of benefits
Gold – covers 80% of actuarial value of benefits
Platinum – covers 90% of actuarial value of benefits
!Catastrophic – high-deductible plan for individuals up to age 30 or individuals exempted from the mandate to purchase coverage
*Actuarial value is the percentage of total average costs for covered benefits that a plan will cover.
Exchange Functions & Services
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Find and Compare Health Plans
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QHP Logo QHP Logo QHP Logo
How Is My Personal Information Protected?
The personal information that we collect is used only for authorized purposes.
Your personal information is not disclosed to unauthorized third parties, and may be disclosed in the following authorized situations: To the insurance company whose plan you purchase, to licensed
agents/brokers and Navigators that help you shop for a health plan, to state and federal government (as required by law and specified below), or to administrators for Washington Healthplanfinder business purposes.
To Authorized Service Providers.
We may disclose your personal information to our authorized service providers (e.g., Washington Healthplanfinder Call Center representatives) to help us process or service your insurance application, correspond with you, or process appeals. Such authorized service providers are contractually obligated to maintain confidentiality of personal information received through Washington Healthplanfinder.
Legal Obligations: We may disclose your personal information when the disclosure is permitted or required by law.
Outside of these exceptions, we will not share your personal information with any third parties.
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Let’s Review
▪ Governance
▪ Vision and Mission
▪ Exchange Functions and Services▪ Washington Healthplanfinder Landing pages▪ Qualified Health Plans▪ Individual and Business Eligibility
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What's in it for you?
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Health Plans Marketplace Consumers
Knowledge Check
The Washington Healthplanfinder is an on-line system that is the single point of entry for (mark all that apply)…
A.Individuals and families to apply for Washington Apple Health (Medicaid)
B.Individuals and families to apply for car insurance
C.Individuals and families to apply for Qualified Health Plans
D.Individuals and families to apply for Health Insurance Premium Tax Credits
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Knowledge Check
The Washington Health Benefit Exchange is…
A.A health insurance cooperative
B.A place to exchange email addresses
C.An on-line marketplace for health care coverage
D.Responsible for the oversight of Washington Apple Health
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Knowledge Check
The Exchange in governed by…
A.An Exchange Board
B.Governor Inslee
C.The Secretary of State
D.The Office of the Insurance Commissioner
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Knowledge Check
The Exchange is responsible for (choose all that apply)…
A.Reviewing and Approving Qualified Health Plans
B.Developing and Hosting a Web Site
C.Loading Plan Information into the Healthplanfinder
D.Determining Eligibility through the Healthplanfinder
E.Oversight of Navigator Organizations
F.Writing the Affordable Care Act
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Knowledge Check
In order to be eligible to receive a Health Insurance Premium Tax Credit….
A.Health care coverage must be purchased through any private Insurance Agent.
B.Health care coverage must be applied for.
C.Health care coverage is not necessary.
D.Health care coverage must be purchased through the Washington Healthplanfinder.
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Knowledge Check
The Exchange is responsible for (choose all that apply)…
A.Displaying Tax Credits and Eligibility
B.Certifying Navigators/In-person Assisters
C.Aggregating Premiums and sending payment to Carriers
D.Providing Customer Support
E.Offering Homeowner’s Insurance
F.Developing and hosting a web site
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Knowledge Check
The Washington Healthplanfinder will integrate with the Federal system to verify (mark the answer that does not apply)…
A.Citizenship
B.Income
C.Dental Records
D.Social Security numbers
E.Identification of the individual applying
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Knowledge Check
The following is NOT an example of personal information:
A.Phone number
B.Date of Birth
C.Favorite food
D.Social Security number
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Questions
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Thank you!
Congratulations! You have completed theExchange 101 course!
http://wahbexchange.org/
Includes information about:▪ Exchange Board
▪ Legislation and grants
▪ Policy discussion
▪ Technical Advisory Committees and stakeholder involvement
▪ IT systems development
▪ HHS guidance
▪ Listserv registration
▪ Healthplanfinder Calculator: http://www.wahealthplanfinder.org/
▪ Contact the Exchange at: [email protected]
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More on the Exchange
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Appendix: Glossary of Terms
▪ Actuarial Value: The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy.
▪ Affordable Care Act: The comprehensive health care reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The name “Affordable Care Act” is used to refer to the final, amended version of the law.
▪ Catastrophic Plan: Currently, some insurers describe these plans as those that only cover certain types of expensive care, like hospitalizations. Other times insurers mean plans that have a high deductible, so that your plan begins to pay only after you've first paid up to a certain amount for covered services.
▪ Cost Sharing: The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. Cost sharing in Medicaid and CHIP also includes premiums.
▪ Deductible: The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
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Glossary of terms cont.
▪ Donut Hole, Medicare Prescription Drug: Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a "donut hole"). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.
▪ Federal Poverty Level (FPL): A measure of income level issued annually by the Department of Health and Human Services. Federal poverty levels are used to determine your eligibility for certain programs and benefits.
▪ Grandfathered Health Plan: As used in connection with the Affordable Care Act: A group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions. (Note: If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to grandfathered group plans after March 23, 2010).
▪ Modified Adjusted Gross Income: MAGI is the new methodology for calculation of income for certain Medicaid programs which closely mirrors how the IRS determines adjusted gross income and household composition for tax purposes. This simplified income calculation will be used to determine Medicaid eligibility and also by the Exchange to determine Health Insurance Premium Tax Credits.
▪ Open Enrollment Period: The period of time set up to allow you to choose from available plans, usually once a year.
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Glossary of terms (cont.)
▪ Out-of-Pocket Costs: Your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.
▪ Premium: The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
▪ Prescription Drug Coverage: Health insurance or plan that helps pay for prescription drugs and medications.
▪ Primary Care Physician: A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
▪ Provider: A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.
▪ Qualified Health Plan: Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by an Exchange, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Exchange in which it is sold.
▪ Source: Health and Human Services For more terms please visit: http://www.healthcare.gov/glossary/a/index.html
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