Washington Health Benefit Exchange
Exchange 101
Summer 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
2013
2012
• Exchange must be certified by HHS
• Board begins governing Exchange Operations
• Exchange names first CEO and moves
into new building
2011
• HCA receives one-year grant
to design and develop
Exchange
• SSB 5445 passed creating
Exchange as “public private
partnership”
• Governor names Exchange
Board members
• Washington receives a Level 2
establishment grant
• Open Enrollment begins
October 1
2014
• Coverage purchased in the
Exchange begins January 1
• Sustainability plan
submitted to Legislature
• WA HBE receives
conditional approval to
operate the state
exchange
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Governance Structure
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Employee benefits specialists
Health care finance specialists
and economists
Health consumer advocates
Small business representatives
Administrators from public
and private health care
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Consumer advocates
Health insurance carriers
Health insurance brokers
Health care providers
Tribal representatives
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Technical experts
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Consumers
Consumer advocates
Health insurance carriers
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
Business Exchange
Who:
- Individuals and families who are not
covered by an employer provided plan
What:
- Access to Medicaid, QHPs, federal
subsidies through health insurance tax
credits or other cost reductions
When:
- 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
- Small businesses with up to 50
employees
- Employer ability to define their
percentage of contributions and access
to small business tax credits
- Employee access to employer
sponsored plans with increased choice
- Open for enrollment 10/1/2013 for
coverage effective 01/01/2014
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Exchange Functions & Services
Develop,
Host
Website
Highlight
Products,
Oversee
Navigators
Customer
Support,
Quality
Rating
System
Review &
Certify
Qualified
Plans
Determine
Eligibility,
Tax Credits
Aggregate
Premiums
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Exchange Functions & Services
Develop,
Host
Website
Highlight
Products,
Oversee
Navigators
Customer
Support,
Quality
Rating
System
Review &
Certify
Qualified
Plans
Determine
Eligibility,
Tax Credits
Aggregate
Premiums
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How will people get health care coverage?
Agent
Broker
Navigator
In-person
Assister
Customer
Support
Center
Website
Partner
SelfDirected
Exchange Functions & Services
Develop,
Host
Website
Highlight
Products,
Oversee
Navigators
Customer
Support,
Quality
Rating
System
Review &
Certify
Qualified
Plans
Determine
Eligibility,
Tax Credits
Aggregate
Premiums
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Exchange Functions & Services
Develop,
Host
Website
Highlight
Products,
Oversee
Navigators
Customer
Support,
Quality
Rating
System
Review &
Certify
Qualified
Plans
Determine
Eligibility,
Tax Credits
Aggregate
Premiums
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Washington Healthplanfinder
Homepage
QHP Logo
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Individual Landing Page
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Decision Support Tools
▪ 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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SORT
QHP Logo
FILTER
QHP Logo
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QHP Logo
PLAN
WIZARD
QHP Logo
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HC PROVIDER
SEARCH
QHP Logo
QHP Logo
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Exchange Functions & Services
Develop,
Host
Website
Highlight
Products,
Oversee
Navigators
Customer
Support,
Quality
Rating
System
Review &
Certify
Qualified
Plans
Determine
Eligibility,
Tax Credits
Aggregate
Premiums
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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
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.
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Exchange Functions & Services
Develop,
Host
Website
Highlight
Products,
Oversee
Navigators
Customer
Support,
Quality
Rating
System
Review &
Certify
Qualified
Plans
Determine
Eligibility,
Tax Credits
Aggregate
Premiums
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Find and Compare Health Plans
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QHP Logo
QHP Logo
QHP Logo
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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?
Health Plans
Marketplace
Consumers
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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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Congratulations! You have completed the
Exchange 101 course!
Thank you!
More on the Exchange
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: info@wahbexchange.org
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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-ofpocket 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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