State Insurance Exchange & Individual Plans Presented by D. Mark Baker, Director of Healthcare Access, Lifelong

wahealthplanfinder The wahealthplanfinder is administered by the Washington Health Benefit Exchange Washington developed its own ‘state-based’ exchange ▫ Still connects with Federal hub  Homeland security  IRS Joint private public entity ▫ Funding continues to be a concern OIC role ▫ Regulate carriers, advocates for consumers, approve plans, and approves rates

Washington Health Benefit Exchange Washington Health Benefit Exchange created a sponsorship program for third party payers ▫ Based on the existing navigator program ▫ Allows ‘sponsorship representative’ to see a client/patient’s account and make changes The Exchange created a premium aggregation process that the board voted to discontinue ▫ EHIP is already paying most carriers directly to combat the payment issues with premium aggregation

Plans offered in the Exchange Carriers8 Platinum0 Gold10 Silver17 Bronze12 Catastrophic2 Total41 Carriers10 Platinum5 Gold22 Silver53 Bronze29 Catastrophic2 Total111

2016 Plan Applications (total) Platinum17 Gold57 Silver99 Bronze70 Catastrophic3 Total of the plan applications below are offered outside of the Exchange 188 applications are for plans in the Exchange

2016 Applications OIC has received applications from 13 carriers who have filed 188 plans for the Exchange in 2016 Only 24 plans carry over to 2016 Clients/patients need to be aware that several carriers have discontinued old plans and only offer new plans Five new carriers applied this year. Time, Asuris, Regence (of Oregon) United, and Health Alliance

Plan Selection for EHIP Working with DOH, EHIP reviews and evaluates plan benefits annually Determine the most cost effective plans based on Rx coverage and other factors In general, EHIP can pay for Silver, Gold, and Platinum plans on the Exchange Also pays for employer sponsored insurance, Medicare Part D, and individual plans outside the Exchange

Exchange Plan Benefits Rx ▫ Formularies  The formularies in WA are comprehensive and cover most medications. ▫ Tiering for single tab regimens  Tier %  Tier 2 – 30%  Tier 3 – 23%  All other Tiers and categories - 30% Network adequacy ▫ Community provider concerns ▫ Micro networks

Coordination with Ryan White 45 CFR Part 156 ▫ Requires carriers that offer plans on the Exchange to accept third party payments from Ryan White providers ▫ Debatable if this includes plans outside the Exchange Sponsorship ▫ WA Health Benefit Exchange developed a method for sponsorship ▫ EHIP is the largest sponsorship organization

Status Issues affecting providers and consumers ▫ Network adequacy and changes ▫ High out of pocket maximums ▫ Prior authorization for drugs and services  PrEP  ARV