Washington Health Benefit Exchange Cascade Care Discussion WSHIP - PowerPoint PPT Presentation

Washington Health Benefit Exchange Cascade Care Discussion WSHIP Board Meeting September 25, 2019 Molly Voris, Chief Policy Officer

Washington Health Benefit Exchange ▪ Quasi-governmental entity ▪ Governed by 11-member bipartisan board ▪ Runs Washington Healthplanfinder , which serves one in four Washingtonians ▪ Single integrated online portal for both MAGI Medicaid (1.5 million) and commercial individual market coverage (200,000) ▪ Offer financial assistance through Medicaid and tax subsidies for low- and middle-income individuals in private insurance 2

In Individual Market Covers 4% of f Washingtonians Office of Financial Management Forecasting & Research Division 3

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80% of f In Individual Market Obtains Coverage Through Washington Healthplanfi finder Office of Insurance Commissioner: February WA Individual Market Enrollment 5

Cascade Care Response to rising premiums and deductibles and declining enrollment in the individual market and failure to enact reinsurance  Standard Plans: Goal to make care more accessible by lowering deductibles, making cost-sharing more transparent, and providing more services before the deductible.  Public Option Plans: Goal to make more affordable (lower premium) options available across the state, that also include additional quality and value requirements  Subsidy Study: Goal to develop and submit a plan for implementing premium subsidies through Exchange for individuals up to 500% FPL (report due Nov. 15, 2020) 6

Public Option Details: Standard Pla lans ▪ HBE can establish up to three standardized benefit plans for each metal level ▪ Starting in PY 2021, QHP carriers must offer at least one gold and one silver standardized plan, and one bronze ▪ Carriers may also offer non-standardized plans ▪ HBE, with the Office of the Insurance Commissioner, required to study the impact of offering only standard plans - due to the Legislature by December 1, 2023 ▪ State procured public option plans must incorporate standardized benefit design ▪ Annually, HBE can update standard benefit design; must provide notice to carriers by January 31 and include a public comment period 7

Public Option Details: State Procurement ▪ The purchasing authority, in consultation with HBE, required to selectively contract with carriers to offer bronze, silver, and gold state procured QHPs for plan year 2021 ▪ Contracts require OIC approval and HBE Board certification complete ▪ Carrier participation in the public option is voluntary ▪ Study required on impact of linking carrier and provider participation in the of publicly procured QHPs, with participation in public employee programs (due December 1, 2022) ▪ Provider reimbursement rates are tied to Medicare rates, expected to lower premiums ▪ Carriers must meet additional requirements focused on increasing quality and value ▪ Including Bree recommendations, care coordination and chronic disease management 8

Public Option Details: Reimbursement Rate Requirements ▪ Aggregate Cap: Total amount carrier reimburses providers and facilities cannot exceed 160% of Medicare ▪ Primary Care Physician Floor: Reimbursement for primary care services (defined by HCA) may not be less than 135% of Medicare ▪ Rural Floor: Reimbursement for services provided by rural hospitals (critical access hospitals or sole community hospitals) may not be less than 101% of Medicare (allowable costs) 9

Three Different Types of Health Plans in the Exchange in 2021: Non-Standard Plans, Standard Plans, and Public Option Plans Non-Standard Standard Plans Public Option Plans (Standard Plans Plus) Plans    Offered through the Exchange and eligible for federal tax subsidies    Subject to full regulatory review by OIC, including network adequacy and rate review requirements    Adheres to 19 Exchange certification criteria for QHPs    Meets federal actuarial value requirements for metal levels    Includes Essential Health Benefits   Uses plan design with deductibles, co-pays, and co-insurance amounts set by Exchange for each metal level (bronze, silver, gold)   Some services guaranteed to be available before the deductible   Allows consumers to easily compare plans based on premium, network, quality, and customer service  Procured by HCA (Could result in one or more plans per county)  Required to incorporate Bree Collaborative and Health Technology Assessment program recommendations  Caps aggregate provider reimbursement at 160% of Medicare  Subject to a floor on reimbursement for primary care services (135% of Medicare) and reimbursement of rural hospitals (101% of cost)  Requires carriers to offer a bronze plan (in addition to silver and gold)  Carriers required to offer to participate in the Exchange 10

Interagency Cascade Care In Implementation Timeline Im HBE June 2019 July 2019 August 2019 September 2019 October 2019 January 2020 September 2020 December 2019 May 2020 First draft of Finalize Stakeholders Second draft standard standard Federal AV calculator Board Standard discuss policy of standard Begin plan designs plan finalized; standard plan certifies plan issues using plan designs Public standard presented to designs 2021 designs updated if stakeholder first draft of presented to Comment plan stakeholders and necessary plans group SPs and stakeholders Period design and present commences feedback and feedback feedback for Board received received received approval HCA September 2020 June 2019 September 2019 October 2019 December 2019 January 2020 May 2020 Review RFP submissions Develop RFP criteria including value, quality, care management, and negotiate contracts for HCA procurement process and reimbursement rate requirements, in consultation with HBE 2021 public option plans (tentative) Participate in standard plan stakeholder group OIC September 2020 March/April 2020 May 2020 June 2019 September 2019 October 2019 December 2019 January 2020 Publish filing Filing Review and approve instructions deadline 2021 plans (tentative) (tentative) Participate in standard plan stakeholder group

St Standard Pla lans: Number of f St Standard Pla lans at t Each Metal Le Level ▪ First drafts of standard plans include 2 plans per metal level for comparison purposes Gold Silver Bronze Range: 76%-82% AV Range: 66%-72% AV Range: 56%-65% AV ▪ Two standard gold plans – high actuarial value (81% AV) and low AV (77% AV) ▪ Two silver plans – a 70% AV and a 71% AV ▪ Two bronze plans – high AV (65% AV) and mid AV (62% AV) ▪ Goal was to provide meaningfully different plan designs at each metal level ▪ Exchange could identify one or more plans at a metal level as required, and could make some plan designs optional ▪ Expect to finalize 1-2 standard plans per metal level 12

Standard Pla lans: Services Before Deductible ▪ Draft plans place outpatient services before deductible to drive appropriate utilization to the extent possible, including office visits and some prescription drugs ▪ Generic and preferred brand drugs before deductible in all metal levels ▪ Silver plans includes primary care visits, specialist visits, mental/behavioral health and substance use disorder outpatient services, urgent care, and physical therapy ▪ Bronze plan includes access to some services before deductible, including primary care, specialist, and urgent care visits ▪ High-AV gold plan designed for a higher utilizer; e.g., includes pre-deductible coverage of outpatient surgery and all Rx categories 13

Estimated Premium Im Impacts of f St Standard Pla lans ▪ Wakely estimated how standard plan designs could impact current plan premiums ▪ Premium impacts across range of current plans estimated to result in: ▪ Decrease of 9.7% to an increase of 4.8% at the gold level ▪ Decrease of 2.2% to an increase of 1.6% at the silver level ▪ Decrease of 3% to an increase of 5.2% at the bronze level ▪ For context, % of current enrollees in each metal level: ▪ Bronze - 37% ▪ Silver - 51% ▪ Gold - 11% 14

Standard Pla lan Designs Overv rview Notes: • Alternate 1 includes a per admission co-pay and Alternate 2 includes a per-day, limit of 5 • Services shaded in blue not subject to the deductible 15

Standard Pla lan Designs Overv rview Notes: Inpatient Hospital Services is a per day co-pay, 5 days maximum Services shaded in blue not subject to the deductible. 16

Standard Pla lan Designs Overv rview Notes: • Services shaded in blue not subject to the deductible • $300 cap on specialty drugs in alternate plans 17

Public Option Im Implementation Challenges Defining benchmark Carrier participation calculation (160%) Provider participation/network Premium impact adequacy Ongoing federal and regulatory activity and impact on consumers 18