1. Alan R. Zalewski, CLU, ChFC
HEALTH CARE REFORM
Washington HealthPlan Finder State Insurance Exchange, the Affordable Care Act January 1, 2014,
Alan R. Zalewski, CLU, ChFC

2. A Fish Story

3. TWIN GOALS OF ACA
Accessible – No one can be denied health insurance or treatment by an insurance company .
Affordable – Everyone has access to low cost, high quality health insurance and, therefore, health care.

4. History of the Affordable Care Act
Signed into law March 23, 2010
Requires everyone to have health insurance in 2014
Creates state-based exchanges
Reforms insurance market – all can get insurance regardless of age or health
Establishes an essential benefit package
Provides individual subsidies
Creates Employer mandate to “Play or Pay”

5. MINIMUM LOSS RATIO
80% of All Premium must be paid out in benefits for individuals and small groups (< 50 Employees)
85% of premium paid out in benefits for Large Groups (> 50 Employees)
Failure to meet Requirement forces Rebate back to policyholders

6. WA Health Insurance Exchange

7. WASHINGTON HEALTH PLAN FINDER
The Exchange was created in state statute in 2011 by SSB 5445
Established as a “public-private partnership” separate and distinct from the state
In 2012, legislation was passed (ESSHB 2319) that established market rules, requirements for QHPs, essential health benefits 

8. HISTORY OF EXCHANGE
The Exchange initially started in the state’s Health Care Authority (HCA) and has transitioned to an independent organization
The Exchange will offer Plans that meet the “Metallic” Tiers: Bronze, Silver, and Gold. There will not be any Platinum Plans in 2014 
Plus a catastrophic plan for those under age 30
No one can be denied insurance coverage based on health status, and there will be no pre-existing conditions waiting periods or limitations under the ACA as of January 1, 2014

9. The Exchange Continued
Essential Health Benefits will include outpatient care, inpatient hospital care, prescriptions, lab and X-ray services, habilitative and rehabilitative care, maternity and related care, mental health and substance abuse care, doctors’ services, and preventive care, plus pediatric dental care.
“Washington Healthplanfinder” is a central location where multiple health insurance companies compete 
Goal: make side-by-side comparisons of multiple health insurance plans

10. NOTE!
Only Plans that have been certified as “Qualified Health Plans” will be available on the Exchange, assuring quality to consumers
Major Benefit to Individuals and Families: Tax credits or financial help to pay for co-pays and premiums

11. How does the Tax Credit/Subsidy Work?
in 2014, many individuals and families will be eligible to receive subsidized coverage in the Exchange if they are not eligible for Medicare, Medicaid or the Children's Health Insurance Program and are not offered affordable coverage through their employer*
* Affordable by IRS definition = < 9.5% of employee income for employee only coverage.

12. SUBSIDY CONTINUED
The Subsidy is an Advanced Tax Credit that can either be taken immediately each month or deferred until year end filing of income taxes.
Subsidies available to households who make less than 400% of the Federal Poverty Level (FPL).
Individuals/Families at less than 138% of the FPL will receive Apple Health (Medicaid) at no cost.
Individuals/Families between 138% and 250% will be eligible for not only premium subsidies but additional assistance with co-pays and cost sharing, based on the second lowest cost Silver Plan in their area.

13. Range of Household Income to Qualify
Household Size
100% FPL
133% FPL
200% FPL
400% FPL 1
$11,490
$15,282
$22,980
$45,960 2
$15,510
 S20,628
$31,020
$62,040 3
$19,530
$25,975
$39,060
$78,120 4
$23,550
$31,322
$47,100
$94,200

14. Many have not yet received their producer ID
Will Licensed Insurance Producers be able to offer plans on the Exchange?
Yes, but you must be “certified” and also licensed and appointed with the carriers offering QHP on the Exchange.
Producers are compensated directly by the carriers themselves, and not the Exchange
Many have not yet received their producer ID

15. Certified Producer will receive:
A password-protected login and dashboard to track their client database, client contact information and application status
A unique profile for each agent and broker in the Washington Healthplanfindersystem will allow consumers and small businesses to easily locate them by name or zip code
Customer service will be available to answer questions and provide support to producers as they work with clients

16. Open Enrollment October 1, 2013 - March 31, 2014
Application must be made by the 25th of December to be effective on Jan 1, 2014 
Thereafter, application must be completed and received by 25th of the month to be effective for 1st of following month.
If application received between 26th and 31st of month, then plan is effective 1st of the second following month. (i.e., latest signup March 31st equals coverage effective date of May 1, 2014)

17. Customer Service Center is Now Open
1-855-WAFINDER ( ) Toll Free
Available Weekdays 7:30 AM to 8 PM
Also

18. New Plans in the Exchange

19. Plans That Will Be Offered for Individual Coverage
Bridgespan
– King, Kitsap, Pierce, Skagit, Snohomish, Thurston, and Spokane
Note: Bridgespan is a Non-Blue Shield Subsidiary of Regence Blue Shield

20. 2014 Bridgespan vs. 2013 Regence - King County Rates – Non-Smoker
Age
Evolve Plus
$1,000 Deductible
Gold
Evolve Core
$2,500 Deductible
Silver
$3,000 Deductible
Bronze
$5,000 Deductible 30
$361.00
$308.23
$166.00
$266.73
$211.10 35
$427.00
$331.86
$196.00
$287.17
$227.28 40
$502.00
$347.07
$231.00
$300.33
$237.70 45
$607.00
$392.15
$279.00
$339.34
$268.57 50
$723.00
$485.02
$333.00
$419.71
$332.18 55
$848.00
$605.60
$390.00
$524.05
$414.76 60
$994.00
$737.04
$457.00
$637.79
$504.78

21. Quick Comparison: Old to New Plans: Evolve Plus to Gold
Evolve Plus Plan
Bridgespan Gold Plan
Deductible
$1,000
Co-Insurance
20%
Out of Pocket Maximum
$6,500
$3,300 In Network; $12,500 Out of Network
Network of Providers
Regence
Real Value Network
Office Visits
First $25 Co-pay, then deductible, coinsurance
Only Primary visits deductible waived
Maternity
Yes
Prescription
$10 Co-pay Generics $500 deductible then 50%
$10 Co-pay Generics, deductible, 30%/50%/40%
Lab and X-Ray
First $400 Paid in Full, deductible, coinsurance
Deductible, coinsurance

22. Plans Community Health Plan of Washington
– 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

23. Plans Group Health Cooperative
– Benton, Columbia, Franklin, Island, King, Kitsap, Kittitas, Lewis, Mason, Pierce, San Juan, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman, and Yakima

24. Plans Molina Healthcare of Washington, Inc. – King, Pierce and Spokane
LifeWise – All 39 counties
Premera Blue Cross – All counties except Clark

25. LifeWise 2013 to 2014 Rates – King County – Non-Smoker
Wise Essentials 6
2014 GOLD
Wise Essentials Co-Pay
2014 Silver
2014 Bronze
Age
$1,970 Deductible
$1,000 Deductible
$5,000 Deductible
$3,000 Deductible
$5,500 Deductible 30
$210.00
$284.40
$155.00
$273.90
$227.29 35
$250.00
$321.51
$188.00
$294.90
$244.71 40
$294.00
$346.15
$220.00
$308.41
$255.93 45
$369.00
$362.02
$276.00
$348.47
$289.17 50
$452.00
$409.04
$339.00
$431.00
$357.66 55
$527.00
$505.92
$393.00
$538.15
$446.57 60
$598.00
$631.69
$446.00
$654.95
$543.50

26. Plans Kaiser Foundation Health Plan of the Northwest
– Clark and Cowlitz (Small Business and Individual Market)
The only Plan in the S.H.O.P. (Small Business Health Options Plan)

27. Plans
Delta Dental of Washington, Kaiser Foundation Health Plan of the Northwest, LifeWise, Premera Blue Cross – (Pediatric Dental Only)

28. What will the new plans look like?
5 Rating Areas
Maximum Ratio of 3 to 1, Oldest to Youngest
Rates not in 5 year bands, but each year
Range of Deductibles and co-pays
There must be a large enough network in the area to support the plan to be certified.
Emphasis on many for a Primary Care Physician to coordinate all care and refer to specialist required, as well as pre-authorization for many services

29. What will the new plans look like?
Charge for each child under Age 20, up to 3 maximum
Charge for each Child over 20 through 26 on parents’ plan
Each adult pays rate for their own age.
Age rate set on effective date and remains so for the year, even if birthday occurs.

30. Medicare Advantage
Medicare and Medicare Advantage rules are not affected as much by ACA and producers should follow all CMS Training and Certification requirements as before.
Expect higher rates in the future as ACA mandated cuts to reimbursement of providers continues.

31. Health Reform Issues:
Both Federal (HHS) and State Governments must approve insurance plans
CBO originally scored ACA at $940 Billion in 2010; now revised to $1.76 Trillion
CBO reports that at least 7 million workers will lose employer coverage
Health Care costs are not going down; indeed are going up for most and younger.

32. Issues (2)
CBO reports that 1 Year delay of Employer Mandate to cost another $12 Billion
Employers in face of uncertainty not hiring and shifting employees to part time (<30 hours)
WA State Medical Assoc found that 18% primary care doc had dropped Medicaid; 24% not taking new patients

33. (LATEST!) Issues (3)
Tues Oct 22nd: Federal Judge allows lawsuit on Premium Subsidies Program in HHS Run States
Will rule by Feb 15, 2014 as the current effective date of Individual Mandate.
Thurs Oct 24th: Administration announce delay by 6 weeks of requirement to enroll (from Feb 15th to March 31st, 2014)

34. THANK YOU! QUESTIONS?

35. THANK YOU! Questions? Alan R. Zalewski, CLU, ChFC, LUTCF
1919 North Pearl, Suite B-3
Tacoma, WA