Ernie Sweat CEBS Utah Health Exchange Advisory Board

Transcription

1 Ernie Sweat CEBS Utah Health Exchange Advisory Board

2 Limited to small employers (2-50) One of two operational exchanges in the country Market Driven Up to 114 plans available

3 Regence Blue Cross Blue Shield United Healthcare Select Health Humana

4 Regence Blue Cross Blue Shield United Healthcare Select Health Humana

5 $43/Subscriber $37 to agent $6 to administrators Added to Raw Rates Included for all enrollees (even without agent)

6 Bswift Health Equity

7 Prospective Risk Adjustment Retrospective Risk Adjustment

8 Employees Complete Universal Applications Two Carriers in Exchange are Randomly Selected to Underwrite Risk Rateups are Assigned

9 If Carriers are Within 30 points, the Average is Assigned If Outside of 30 Points, a Third Carrier (mediator) is Randomly Selected to Underwrite

10 Average of two Closest Carriers is Taken to Assign Final Rateup CAVEAT: Utah State Law Requires Rate Tables Inside the Exchange to be no Higher than the Underwritten Rate Tables Outside the Exchange

11 Health Score is Assigned to Each Individual in the Group Algorithm is used to Average Health Scores for Employees Selecting Each Carrier Higher Scores Mean a Higher Premium Allotment

12 All Premium is Pooled and then Allocated to Carriers New and Terminated Employees are Added to/subtracted from Algorithm Average Score is Recalculated Monthly

13 High Risk Pooling Claims in Excess of Pooling Level ($75,000) are Identified Only Claims Between $75,000 and $250,000 are Pooled 75% of Each Qualifying Claim is Calculated

14 High Risk Pooling Example: Carrier A: Has a Claim of $100,000 ($25,000 over Pooling Level) $25,000 x 0.75 = $18,750 Carrier B: Has a Claim of $155,000 ($80,000 over Pooling Level) $80,000 x 0.75 = $60,000

15 Example: Carrier A: $25,000 x 0.75 = $18,750 Carrier B: $80,000 x 0.75 = $60,000 Total: $78,750 Tally is Divided by the Membership of the Exchange Example: 15,000 Members = $5.25/Member

16 Each Carrier Multiplies that Figure by Their Total Membership Example: Carrier A: 5,000 Members x $5.25 = $26,250 Amount Determined is Sent to High Risk Pool

17 High Risk Pool Funds are Distributed to Carriers Who Incurred Large Claims Carrier A: $26,250 $18,750 All Dollars from Pool are Distributed to Risk Affected Carriers Settlement Takes Place 6 Months after Plan Year Zero Sum Game

18 Access to Multiple Networks No Minimum Contribution Both Maternity and Non-Maternity plans may be offered No restriction on plan options

19 Exchange 1.0 Bswift Health Equity

20 Exchange 2.0 Bswift Health Equity ehealthapp

21 Exchange 1.0 Attend Defined Contribution Training Session Must be Appointed with the majority of the carriers Exchange 2.0 Attend Updated UHE Training Attend Utah Premium Partnership Training Complete ehealthapp Training Must be appointed with all carriers

22 Exchange 1.0 Requires employer application Cumbersome excel spreadsheet Banking data required upfront Employee application via Bswift Data unavailable outside Exchange

23 Exchange 2.0 Broker registers employer No spreadsheet required Employee application via ehealthapp Broker submits group to underwriting once applications are complete Data can be shared with other carriers as well as Exchange

24 2.0 Advantages Banking data collected AFTER group selects Exchange as carrier Broker owns the application Better visibility of applications Addition of group documents library Marketing materials in development stage

25 Exchange 1.0 Primary and Secondary Underwriter Primary Underwriter collects data via Bswift Secondary Underwriter and Mediator collect data independently

26 Exchange primary Underwriters Each Underwriter receives data automatically from ehealthapp Mediator uses same process Much faster turnaround

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28 Mandated method of employer contribution Must be determined before employees make elections Must also choose default plan at this time Can elect to have excess funds go to HSA account Health Equity Optum Bank

29 Employee data from enrollment forms sent to Bswift Allows employees to have additional time to make selections

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40 Exchange days Generally earlier than renewal date Exchange days Can coordinate with renewal date Holidays may extend this process

41 Exchange 1.0 Handled by Health Equity Funded by broker commission Exchange 2.0 Governed by the Utah Health Exchange Funded by carriers

42 Utilizes Calling Tree Bswift Enrollment Health Equity Billing ehealthapp Group Enrollment Utah Insurance Department Exchange Overview Carriers Claims and specific questions

43 Exchange 1.0 Invoice ed to client on the 5 th of prior month Initial ACH withdrawal takes place on the 8 th of prior month Exchange 2.0 Invoice ed to client on the 17 th of prior month Initial ACH withdrawal takes place 10 days prior to effective date Subsequent ACH withdrawals can be moved to late in billing month

44 Exchange 1.0 Received a trend increase Exchange 2.0 Beginning January 1, 2012 PEHP will underwrite Each group rated separately Will utilize any available information RAB still determining a permanent solution Intending to use All Payer Claim Database

45 Quality and Cost Data on carriers and providers Utilize Utah Health Information Network Mine feedback from consumers

46 Utilize Federal Funds Grants Vouchers

47 Integrate Medicaid Possible training for agents

48 Add the individual market Determine underwriting and risk adjustment process Decide plan designs Likely that these will match the group market

49 Define the role and training of navigators Must they be licensed? Must they carry E&O insurance? Must they be appointed by the carriers? Will the training regimen be different from that of an agent? Will there truly be a distinction between navigator and agent?

50 Addition of the larger employer sector Integration of market Is there a place for 100+??

51 Ernie Sweat