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UTAH HEALTH EXCHANGE 2.0

Ernie Sweat CEBS Utah Health Exchange Advisory Board. UTAH HEALTH EXCHANGE 2.0. Overview of the Utah Health Exchange. Limited to small employers (2-50) One of two operational exchanges in the country Market Driven Up to 114 plans available. 4 Participating Carriers.

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UTAH HEALTH EXCHANGE 2.0

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  1. Ernie Sweat CEBS Utah Health Exchange Advisory Board UTAH HEALTH EXCHANGE 2.0

  2. Overview of the Utah Health Exchange • Limited to small employers (2-50) • One of two operational exchanges in the country • Market Driven • Up to 114 plans available

  3. 4 Participating Carriers • Regence Blue Cross Blue Shield • United Healthcare • Select Health • Humana

  4. 4 3 Participating Carriers • Regence Blue Cross Blue Shield • United Healthcare • Select Health • Humana

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

  6. 2 Administrators • Bswift • Health Equity

  7. Risk Adjustment Prospective Risk Adjustment Retrospective Risk Adjustment

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

  9. Prospective Risk Adjustment • 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. Prospective Risk Adjustment • 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. Prospective Risk Adjustment • 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. Prospective Risk Adjustment • 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. Retrospective Adjustment • 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. Retrospective Adjustment • 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. Retrospective Adjustment • 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. Retrospective Adjustment • 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. Retrospective Adjustment • 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. Uniqueness of the Utah Health Exchange • Access to Multiple Networks • No Minimum Contribution • Both Maternity and Non-Maternity plans may be offered • No restriction on plan options

  19. Administrators • Exchange 1.0 • Bswift • Health Equity

  20. Administrators • Exchange 2.0 • Bswift • Health Equity • eHealthapp

  21. Agent Training/Appointment Requirements • 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. Group Submission • Exchange 1.0 • Requires employer application • Cumbersome excel spreadsheet • Banking data required upfront • Employee application via Bswift • Data unavailable outside Exchange

  23. Group Submission • 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. Group Submission • 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. Prospective Risk Adjustment • Exchange 1.0 • Primary and Secondary Underwriter • Primary Underwriter collects data via Bswift • Secondary Underwriter and Mediator collect data independently

  26. Prospective Risk Adjustment • Exchange 2.0 • 2 primary Underwriters • Each Underwriter receives data automatically from eHealthapp • Mediator uses same process • Much faster turnaround

  27. Rates Released To Agent

  28. Defined Contribution • 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 Enrollment 2.0 • Employee data from enrollment forms sent to Bswift • Allows employees to have additional time to make selections

  30. Timelines • Exchange 1.0 • 90 days • Generally earlier than renewal date • Exchange 2.0 • 60 days • Can coordinate with renewal date • Holidays may extend this process

  31. Call Center • Exchange 1.0 • Handled by Health Equity • Funded by broker commission • Exchange 2.0 • Governed by the Utah Health Exchange • Funded by carriers

  32. Call Center • Utilizes Calling Tree • Bswift – Enrollment • Health Equity – Billing • eHealthapp – Group Enrollment • Utah Insurance Department – Exchange Overview • Carriers – Claims and specific questions

  33. Billing • Exchange 1.0 • Invoice emailed to client on the 5th of prior month • Initial ACH withdrawal takes place on the 8th of prior month • Exchange 2.0 • Invoice emailed to client on the 17th 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

  34. Renewals • 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

  35. Future of Exchange 2.0 • Quality and Cost Data on carriers and providers • Utilize Utah Health Information Network • Mine feedback from consumers

  36. Future of Exchange 2.0 • Utilize Federal Funds • Grants • Vouchers

  37. Future of Exchange 2.0 • Integrate Medicaid • Possible training for agents

  38. Future of Exchange 2.0 • Add the individual market • Determine underwriting and risk adjustment process • Decide plan designs • Likely that these will match the group market

  39. Future of Exchange 2.0 • 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?

  40. Future of Exchange 2.0 • Addition of the larger employer sector • Integration of 51-99 market • Is there a place for 100+??

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