Phil Dyer
Board Member
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.
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.
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
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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
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 customerfriendly eligibility determination process.
 Enhance health plan competition on value -price, access, quality, service, and innovation.
WA Exchange Major Committees
 Operations
 Chair, Melanie Curtice
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Steve Appel
Bill Baldwin
Don Conant
 Margaret Stanley
 Policy
 Chair, Teresa Mosqueda
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Doug Conrad
Ben Danielson
Phil Dyer
 Margaret Stanley
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:
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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
Exchange Board
Technical Advisory Committees
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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.
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
State Action Toward Creating
Health Insurance Exchanges
As of August 24, 2012
Washington is a Leading State in the Process of Securing $178
Million for Exchange Establishment & Medicaid Eligibility Systems
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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.
Exchange Functions
Consumer 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
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
Exchange Value – Specific Functions
I. Issuers of
QHPs
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II. Health
Care Market
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III. Public
and State
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Marketing & Outreach
Eligibility Determination for
tax credits
Enrollment
Premium Aggregation
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Easy plan comparison and
purchase of health insurance
Reporting of cost/quality
metrics
Awareness of need for health
insurance
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Appeals of eligibility
determinations and individual
responsibility
Information on health
insurance carriers
Customer Service
Enrollment reconciliation with
HHS
New Membership opportunity –
previously uninsured
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Supporting use of innovative
product designs and payment
methodologies
Expanded access to health
insurance coverage
Reduced charity care
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Trustworthy source of health
care reform information
Broad-based Public
Information
Other impacts of ACA
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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
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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
Exchange Functions
SMALL BUSINESS HEALTH OPTIONS (SHOP)
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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.
Coverage Continuum in 2014
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* Federal Basic Health Plan Option for individuals with incomes between 138% and
200% of the FPL will not be available in 2014.
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To-Be Landscape: Continuous Coverage
Medicaid Standard
CHIP
Family Planning Extension
Take Charge Family Planning
Psych. Indigent Inpatient Program
Involuntary Treatment Act
ADATSA
Basic Health Plan
Medicaid Standard
Medicaid Benchmark
CHIP
QHP with Subsidy
QHP without Subsidy
Medical Care Services Program
SSI Presumptive
Note: Transition options to be addressed by State Legislature.
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Post Implementation of the Affordable Care Act (ACA):
Subsidized Coverage
Landscape in Washington
1.16 million
current
enrollees
Individuals (in
thousands)
545,000
currently eligible
but not enrolled** 494,000
newly eligible
532,000
eligible for subsidies
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4
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
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Authority for Medicaid/CHIP enrollment.
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
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THE “METALLICS”
Four Levels of Benefits
Bronze
Silver
Gold
Platinum
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:
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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
Timeline of Key Tasks: Much Work To Be Done
Sept 30 2012: Deadline to select
benchmark Essential Health Benefits
plan.
Jan 1 2014:
Exchange goes live.
Nov 16, 2012: Request
federal certification
for Exchange
operations.
2012
Aug 15, 2012:
First of ten
new
opportunitie
s to apply for
Exchange
grants
October 2012:
Complete business rules
and workflow for all
eligibility & enrollment
operations.
2013
Jan 1 2013:
Dec 31 2014:
Exchanges must
be selfsustaining.
Oct 1 2013: Open
enrollment begins.
2014
July 1 2013:
Finalize QHP
contracts.
→ Receive conditional or full
exchange certification from
Secretary.
→ QHP solicitation bids due.
→ Initiate marketing & outreach
campaign.
Nov 2014:
Last Exchange
Establishment
application
deadline.
→ Launch assisters training
program.
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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
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Questions