Washington Healthplanfinder Individual Market September 4, 2013 SUPPLEMENTAL 2014 Qualified Health Plan and Qualified Dental Plan Certification Requests
Summary of Individual Market Overview Gold Silver 6 Issuers 33 QHPs up to 91 plans, including cost-sharing variations No Platinum Plans 8 more QHPs through Federal OPM issuing conditional certification for multi-state plans. 6 Issuers 8 Plans 6 PPO 2 HMO 6 Issuers 12 Plans 6 PPO 2 PPO HSA 3 HMO 1 HMO HSA Bronze Catastrophic Stand-Alone Pediatric Dental 6 Issuers 11 Plans 5 PPO 3 PPO HSA 2 HMO 1 HMO HSA 2 Issuers 2 Plans 2 HMO No statewide, Group Health and Kaiser 4 Issuers 4 QDPs 3 PPO 1 HMP No High Plans All Low 70% AV plans 1
Washington State QHP Issuers Per County Whatcom Okanogan San Juan Skagit Ferry Pend Oreille Island Stevens Clallam Snohomish Jefferson Chelan Grays Harbor Mason Kitsap Thurston Pierce King Kittitas Douglas Grant Lincoln Adams Spokane Whitman Pacific Wahkiakum Lewis Cowlitz Clark Skamania Klickitat Yakima Benton Franklin Garfield Columbia Asotin Walla Walla QHP Issuers Per County 2 3 4 5
Certification Criteria Status by Issuer Issuer Submission Form Participation Agreement Health Issuer Initiate Certification Request #1 Certificate of Good Standing #6 Accreditation #2 & #3 Attestations (incl. User Fees and Risk Adj. Program) #7 Marketing Materials #9 Provider Directory #10 Quality Improvement Strategy Form #11 Standard Summary of Benefits BridgeSpan X X X X X X X X CHPW X X X X X X X X Group Health Cooperative Kaiser Foundation Health Plan of the Northwest X X X X X X X X X X X X X X X X LifeWise X X X X X X X X Premera X X X X X X X X Dental Issuer Delta Dental of WA Kaiser Northwest X X X X X X X X X X X X LifeWise X X X X X X Premera X X X X X X 4
Certification Criteria Status by Issuer Health Issuer #4 Market Rules #5 Non- Discrimination #8 Network Adequacy #13 Std Enrollment Form #14 Hospital Contracts #15 Direct Primary Care w/ QHP Issuer #16 Benefit Design Standards #17 Rates and Service Area #19 Benefit and Rate Data for public disclosure BridgeSpan X X X 2014 X 2014 X X X CHPW X X X Group Health Cooperative Kaiser Foundation Health Plan of the Northwest X X X 2014 X 2014 X X X X X X 2014 X 2014 X X X LifeWise X X X 2014 X 2014 X X X Premera X X X 2014 X 2014 X X X Dental Issuer Delta Dental of WA Kaiser Northwest OIC Regulatory Process X X X X X X X X X X LifeWise X X X X X Premera X X X X X 5
Community Health Plan of Washington Qualified Health Plan
Community Health Plan of Washington Plan Premium Rate Ranges: Deductible Metallic Level Counties Covered CHPW Community Gold CHPW Community Silver CHPW Community Bronze $340.38 - $390.33 $281.34 - $323.19 $231.12 - $265.03 $388.75 - $445.79 $321.88 - $369.11 $263.96 - $302.69 $825.56 - $949.69 $683.56 - $783.86 $560.55 - $642.80 $1000 Gold *See Below $3000 Silver *See Below $5000 Bronze *See Below *Coverage in 26 counties: Adams, Benton, Chelan, Clark, Cowlitz, Douglas, Ferry, Franklin, Grant, Grays Harbor, King, Kitsap, Lewis, Okanogan, Pacific, Pend Oreille, Pierce, Skagit, Snohomish, Spokane, Stevens, Thurston, Wahkiakum, Walla Walla, Whatcom, Yakima Essentials Gold:
Community Health Plan of Washington Community Gold: $500 Annual Deductible $4,800 Annual Out of Pocket Maximum Tier 1: $10 copay Tier 2: $40.00 copay, subject to deductible Tier 3: 50% coinsurance, subect to deductible Tier 4: 50% coinsurance, subject to deductible. 20% coinsurance subject to deductible $30 copay Office Visit Cost Share $40 copay Specialty Visit Cost Share Pharmacy Cost Share Hospital Cost Share $250 copay Emergency Cost Share In-Network primary and specialty office visit copays, generic drug copays, and emergency and urgent care services copays are not subject to deductible. Rate Range $340.38 - $390.33 $388.75 - $445.79 $825.56 - $949.69 Rating Area 1 $354.20 $404.53 $859.06 Rating Area 2 $378.64 $432.44 $918.34 Rating Area 3 $361.64 $413.02 $877.10 Rating Area 4 $340.38 $388.75 $825.56 Rating Area 5 $390.33 $445.79 $946.69 Tobacco Rates Rate Range n/a n/a n/a Rating Area 1 n/a n/a n/a Rating Area 2 n/a n/a n/a Rating Area 3 n/a n/a n/a Rating Area 4 n/a n/a n/a Rating Area 5 n/a n/a n/a
Community Health Plan of Washington Community Silver: CSR Plan Variations 73% AV 87% AV 94% AV (200-250% FPL) (150-200% FPL) (100-150% FPL) $2,000 Annual Deductible $2,000 $250 $0 $6,350 Annual Out of Pocket Maximum In-Network primary and specialty office visit copays, generic drug copays, and emergency and urgent care services copays are not subject to deductible. $5,200 $2,250 $1,000 $30 copay Office Visit Cost Share $12 $10 $3 $55 copay Specialty Visit Cost Share $35 $20 $5 Tier 1: $15 copay Tier 2: $50 copay, subject to deductible Tier 3: 50% coinsurance, subect to deductible Tier 4: 50% coinsurance, subject to deductible 30% subject to coinsurance deductible Pharmacy Cost Shares Tier 1: $12 Tier 2: $35 Tier 3: 50% Tier 4: 50% Tier 1: $10 Tier 2: $20 Tier 3: 50% Tier 4: 50% Hospital Cost Share 20% 10% 0% $250 copay Emergency Cost Share $250 $150 $25 Tier 1: $3 Tier 2: $5 Tier 3: 50% Tier 4: 10% Rate Range $281.34 - $323.19 $321.88 - $369.11 $683.56 - $783.86 Rating Area 1 $293.28 $334.95 $711.30 Rating Area 2 $313.51 $358.06 $760.38 Rating Area 3 $299.43 $341.98 $726.24 Rating Area 4 $281.84 $321.88 $683.56 Rating Area 5 $323.19 $369.11 $783.86 *Tobacco Rates - N/A
Community Health Plan of Washington Community Bronze: $5,000 Annual Deductible $6,350 Annual Out of Pocket Maximum Tier 1: $25 copay Tier 2: 50% coinsurance, subject to deductible Tier 3: 50% coinsurance, subect to deductible Tier 4: 50% coinsurance, subject to deductible 0% coinsurance, subject to deductible $500 copay subject to deductible $45 copay Office Visit Cost Share $75 copay Specialty Visit Cost Share Pharmacy Cost Share Hospital Cost Share Emergency Cost Share In-Network primary care and specialist office visits, urgent care services, and generic drug copays are not subject to deductible. Rate Range $231.12 - $265.03 $263.96 - $302.69 $560.55 - $642.80 Rating Area 1 $240.50 $274.67 $583.30 Rating Area 2 $257.09 $293.63 $623.55 Rating Area 3 $245.55 $280.44 $595.55 Rating Area 4 $231.12 $263.96 $560.55 Rating Area 5 $265.03 $302.69 $642.80 Tobacco Rates Rate Range n/a n/a n/a Rating Area 1 n/a n/a n/a Rating Area 2 n/a n/a n/a Rating Area 3 n/a n/a n/a Rating Area 4 n/a n/a n/a Rating Area 5 n/a n/a n/a
Kaiser Foundation Health Plan of the Northwest Qualified Health Plan
Kaiser Foundation Health Plan of the Northwest Plan Premium Rate Ranges: Deductible Metallic Level Counties Covered KP WA Gold 1000/20 KP WA Silver 1500/30 KP WA Silver 2500/30 KP WA Silver 1750/0/HSA KP WA Bronze 4500/50 KP WA Bronze 5000/30%/HSA KP WA Catastrophic 6350/0 $332.88 - $349.52 $292.23 - $306.84 $281.03 - $295.08 $278.14 - $292.05 $261.42 - $274.49 $208.67 - $219.10 $197.47 - $207.34 $380.18 - $399.19 $333.75 - $350.44 $320.96 - $337.01 $317.66 - $333.54 $298.57 - $313.50 $238.32 - $250.24 $225.53 - $236.81 $807.35 - $847.72 $708.76 - $744.2 $681.59 - $715.67 $674.59 - $708.32 $634.05 - $665.75 $506.10 - $531.41 $478.94 - $502.89 $1,000 Gold $1,500 Silver $2,500 Silver $1,750 Silver $4,500 Bronze $5,000 Bronze $6,350 Catastrophic Clark and Cowlitz Clark and Cowlitz Clark and Cowlitz Clark and Cowlitz Clark and Cowlitz Clark and Cowlitz Clark and Cowlitz
Kaiser Foundation Health Plan of the Northwest Gold 1000/20: $1,000 Annual Deductible $4,650 Annual Out of Pocket Maximum $20 copay Office Visit Cost Share $40 copay Specialty Visit Cost Share $10/$30/20% Pharmacy Cost Share 20% after deductible Hospital Cost Share $250 copay Emergency Cost Share Many services covered at copays and not subject to the deductible. Rate Range $332.88 - $349.52 $380.18 - $399.19 $807.35 - $847.72 Rating Area 1 N/A N/A N/A Rating Area 2 $349.52 $399.19 $847.72 Rating Area 3 $332.88 $380.18 $807.35 Rating Area 4 N/A N/A N/A Rating Area 5 N/A N/A N/A Tobacco Rates Rate Range n/a n/a n/a Rating Area 1 n/a n/a n/a Rating Area 2 n/a n/a n/a Rating Area 3 n/a n/a n/a Rating Area 4 n/a n/a n/a Rating Area 5 n/a n/a n/a
Kaiser Foundation Health Plan of the Northwest Silver 1500/30: $1500 medical / $150 Rx Annual Deductible $6,350 Annual Out of Pocket Maximum $30 copay Office Visit Cost Share $50 copay Specialty Visit Cost Share $15/$45 after Rx ded/30% after Rx deductible Pharmacy Cost Share 30% after deductible Hospital Cost Share $350 copay Emergency Cost Share Many services covered at copays and not subject to the deductible. Rate Range N/A N/A N/A Rating Area 1 $306.84 $350.44 $744.20 Rating Area 2 $292.23 $333.75 $708.76 Rating Area 3 N/A N/A N/A Rating Area 4 N/A N/A N/A Rating Area 5 $304.35 $347.60 $738.18 Tobacco Rates Rate Range n/a n/a n/a Rating Area 1 n/a n/a n/a Rating Area 2 n/a n/a n/a Rating Area 3 n/a n/a n/a Rating Area 4 n/a n/a n/a Rating Area 5 n/a n/a n/a
Kaiser Foundation Health Plan of the Northwest Silver 2500/30: $2500 Medical / $250 Rx Annual Deductible $6,350 Annual Out of Pocket Maximum $30 copay Office Visit Cost Share $50 copay Specialty Visit Cost Share $15/$45 after Rx ded/30% after Rx deductible Pharmacy Cost Share 30% after deductible Hospital Cost Share $400 copay Emergency Cost Share Many services covered at copays and not subject to the deductible. Rate Range N/A N/A N/A Rating Area 1 $295.08 $337.01 $715.67 Rating Area 2 $281.03 $320.96 $681.59 Rating Area 3 N/A N/A N/A Rating Area 4 N/A N/A N/A Rating Area 5 $280.88 $320.79 $681.23 Tobacco Rates Rate Range n/a n/a n/a Rating Area 1 n/a n/a n/a Rating Area 2 n/a n/a n/a Rating Area 3 n/a n/a n/a Rating Area 4 n/a n/a n/a Rating Area 5 n/a n/a n/a
Kaiser Foundation Health Plan of the Northwest Silver 1750/0/HSA: $1,750 Annual Deductible $4,750 Annual Out of Pocket Maximum 25% after deductible Office Visit Cost Share 25% after deductible Specialty Visit Cost Share $15/$45/30% all after deductible Pharmacy Cost Share 25% after deductible Hospital Cost Share 25% after deductible Emergency Cost Share HSA qualified HDHP plan. Rate Range N/A N/A N/A Rating Area 1 $292.05 $333.54 $708.32 Rating Area 2 $278.14 $317.66 $674.59 Rating Area 3 N/A N/A N/A Rating Area 4 N/A N/A N/A Rating Area 5 $247.68 $282.87 $600.71 Tobacco Rates Rate Range n/a n/a n/a Rating Area 1 n/a n/a n/a Rating Area 2 n/a n/a n/a Rating Area 3 n/a n/a n/a Rating Area 4 n/a n/a n/a Rating Area 5 n/a n/a n/a
Kaiser Foundation Health Plan of the Northwest Bronze 4500/50: $4500 Medical / $500 Rx Annual Deductible $6,350 Annual Out of Pocket Maximum $30/ $90 after Rx deductible/ 30% after Rx deductible $50 copay Office Visit Cost Share $70 copay Specialty Visit Cost Share Pharmacy Cost Share 20% after deductible Hospital Cost Share $400 copay Emergency Cost Share Many services covered at copays and not subject to the deductible. Rate Range N/A N/A N/A Rating Area 1 $274.49 $313.50 $665.75 Rating Area 2 $261.42 $298.57 $634.05 Rating Area 3 N/A N/A N/A Rating Area 4 N/A N/A N/A Rating Area 5 $267.05 $304.99 $647.69 Tobacco Rates Rate Range n/a n/a n/a Rating Area 1 n/a n/a n/a Rating Area 2 n/a n/a n/a Rating Area 3 n/a n/a n/a Rating Area 4 n/a n/a n/a Rating Area 5 n/a n/a n/a
Kaiser Foundation Health Plan of the Northwest Bronze 5000/30%/HSA: $5,000 Annual Deductible $6,350 Annual Out of Pocket Maximum 30% after deductible Office Visit Cost Share 30% after deductible Specialty Visit Cost Share $20/$50/30% all after deductible Pharmacy Cost Share 30% after deductible Hospital Cost Share 30% after deductible Emergency Cost Share HSA qualified HDHP plan. Rate Range N/A N/A N/A Rating Area 1 $219.1 $250.24 $531.41 Rating Area 2 $208.67 $238.32 $506.1 Rating Area 3 N/A N/A N/A Rating Area 4 N/A N/A N/A Rating Area 5 $198.02 $226.15 $480.26 Tobacco Rates Rate Range n/a n/a n/a Rating Area 1 n/a n/a n/a Rating Area 2 n/a n/a n/a Rating Area 3 n/a n/a n/a Rating Area 4 n/a n/a n/a Rating Area 5 n/a n/a n/a
Kaiser Foundation Health Plan of the Northwest Catastrophic 6350/0: $6,350 Annual Deductible $6,350 Annual Out of Pocket Maximum $0 after deductible Office Visit Cost Share $0 after deductible Specialty Visit Cost Share $0 after deductible Pharmacy Cost Share $0 after deductible Hospital Cost Share $0 after deductible Emergency Cost Share Preventive services covered at no charge. Rate Range N/A N/A N/A Rating Area 1 $207.34 $236.81 $502.89 Rating Area 2 $197.47 $225.53 $478.94 Rating Area 3 N/A N/A N/A Rating Area 4 N/A N/A N/A Rating Area 5 $222.38 $253.98 $539.35 Tobacco Rates Rate Range n/a n/a n/a Rating Area 1 n/a n/a n/a Rating Area 2 n/a n/a n/a Rating Area 3 n/a n/a n/a Rating Area 4 n/a n/a n/a Rating Area 5 n/a n/a n/a