What is WSHIP

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Washington State Health Insurance Pool 2009
WAHU Symposium Presenter Anne Mackie Executive
Assistant
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Agents Make the Difference!
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Todays Topics

• The role of the high-risk pool in todays market
• The Standard Health Questionnaire (SHQ)
• Information about WSHIP the organization,
  benefit plans, and rates
• Why Agents are important!

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Remember when the individual market collapsed

• 1999-2000 Most carriers stopped selling new
  individual products due to rapidly increasing
  claims losses
• Consumers scrambled to find coverage
• 2000 Health Insurance Access Act was
  significantly amended with hopes of bringing
  carriers back into the market

5
Past Legislative changes

• 2000 New legislation allowed enrollment in
  WSHIP for people living in a county where
  individual coverage is not offered
• 2000 Medical underwriting approved for
  individual market, using the Standard Health
  Questionnaire
• 2007 RCW 48.41 modified to allow WSHIP to offer
  more choices in products HSA plan, limited
  benefit plans with lower rates

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WSHIPs role today

• Provides access to health insurance coverage to
  all residents of Washington who are denied health
  insurance the safety net
• Provides comprehensive coverage to those unable
  to obtain it through group or individual coverage
• Maintains a healthy individual market by
  screening out the 8 sickest, which
• Helps to keep individual market rates lower

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WSHIPs role today (cont.)

• Individual market enrollment growth, since
  implementation of the Standard Health
  Questionnaire for medical underwriting
• 2000 120,647 to
• 2007 279,329
• Percent increase since 2000 132
• Efficiently and effectively covers high risk
  people

8
2008 Individual market enrollment

• Total individual market applicants 99,197
• Number / percent accepted for coverage 94,539
  (95.3)
• Number / percent rejected for coverage
• 4658 (4.7)
• Number / percent rejected enrolled in WSHIP 843
  (18.1)

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Efficiency

• For 2008
• Administrative ratio was low 6
• Care management programs 2.3 million savings
  on closed cases
• Provider network 14.5 million savings
• Pharmacy savings 7.7 million
• Medicare SPAP savings 7.2 million

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Effectiveness

• Scores from the Standard Health Questionnaire
  help to identify WSHIP enrollees who can benefit
  from state-of-the-art care management programs
• One local care manager
• Case management improves timely and appropriate
  use of benefits and community resources
• Disease management educates facilitates
  enrollees self-management

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Effectiveness (cont.)

• In 2008 WSHIP added four disease management
  categories for a total of six
• HIV/AIDS
• Depression
• Diabetes
• Asthma
• Coronary artery disease (CAD)
• Congestive heart failure (CHF)

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Standard Health Questionnaire

• A 33-page short form with 218 conditions
• 99,197 people took the SHQ in 2008
• 51,987 online version
• 47,210 paper version
• It is the standardized tool for Washington
  individual market underwriting

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Who develops the SHQ?

• State law mandates WSHIP Board of Directors to be
  responsible for the form and content of the
  standard health questionnaire and the method of
  its application. RCW 48.41.060
• An independent actuary must certify that the
  questionnaire identifies the 8 of persons who
  are the most costly to treat who are under
  individual coverage in health benefit plans

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Standard Health Questionnaire

• SHQ must be recertified every 18 months
• SB5777/HB1713 Bills in Legislature, now, to
  expand time period every 36 months, which will
  save limited resources
• For recertification, carriers selling individual
  products must submit five years claims data
  (medical and Rx)
• WSHIPs own claims data also included
• Actuary analyzes data

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Standard Health Questionnaire

• Claims data processed through the Episode
  Treatment Group (ETG) software to assign each
  claim to an episode of care (ETG)
• Prospective risk score is attached to each ETG
  using cost relativities
• Risk weights are used to calculate a predictive
  risk score for each individual

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Off hand, Id say youre suffering from an arrow
through your head, but just to play it safe, Im
ordering a bunch of tests.
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Standard Health Questionnaire

• Work is underway for October 1, 2009, recertified
  questionnaire
• A public process input provided by
• Agents (12 provided comments)
• Carriers
• WSHIP Board
• OIC and interested parties

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Standard Health Questionnaire

• An industry workgroup reviews all feedback
• 80 items on the SHQ feedback list for 2009
  recertification
• Board Tool Committee reviews / approves
  recommendations forwards to the Board
• Committee chaired by (one of your own)
• Bill Perkins, CEO, GHB Insurance, Olympia
  (Governor-appointed agent rep to the Board)

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SHQ not always used

• Exception 1 if eligible for Medicare

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SHQ not always used

• Exception 2 Your medical insurance ended during
  the last 90 days for any of the following
  reasons
• a. You have used up all of your available COBRA
  coverage
• b. Your former employer, who provided you with
  health coverage, gone out of business while you
  were on COBRA coverage
• c. You changed residences from one part of
  Washington state to another part where your
  current health plan is not offered

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SHQ not always used

• Exception 3 You are adding a newborn, or
  adopted child (regardless of age) during the last
  60 days who you want to add to your existing
  policy
• New issue Coverage for 25 year-old dependent
• (RCW 48.44.215) to be included in revised SHQ
  for October 2009

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SHQ not always used

• Exception 4 You have been covered by a group
  health plan that is exempt from COBRA including
  church plans, for at least 24 continuous months,
  and
• You will lose coverage under that plan within the
  next 90 days
• You lost coverage within the past 90 days

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SHQ not always used

• Exception 5 Your doctor or other health care
  provider stopped being a part of the provider
  network on your current individual medical plan,
  and
• a. Your doctor or provider is on the new health
  plan you are
• applying for, and
• b. You must have had some service from that
  provider during the 12 months before he or she
  left your current health plan, and
• c. You must submit your application to the new
  health plan within 90 days from the day your
  provider left your current health plan's network.

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SHQ not always used

• Exception 6 You have been enrolled in the
  Washington State Basic Health Plan (BHP) for at
  least 24 continuous months and
• a. You will lose your BHP coverage within the
  next 90 days, or
• b. You lost your BHP coverage within the last
  90 days

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New Exemption SHQ issues

• Economic downturn causing more businesses to
  cancel group health insurance
• How does this affect the rules for who must take
  the SHQ?
• How might COBRA rules be affected?
• Working with the OIC for clarification on SHQ
  Exemption rules

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More about WSHIP

• Enrollment growth
• 2,333 in 2002
• 3,397 in 2008
• Growth stunted by
• Lack of awareness about the Pool by people who
  are eligible
• Concern about premium costs lack of awareness
  about lower-cost plan options
• Agents can help!

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More about WSHIP

• 2008 Enrollment 3,397
• Evergreen Health Insurance Program (EHIP),
  serving HIV/AIDS clients 920 enrollees (or 28
  of WSHIPs enrollment)
• Average age 49
• 24 enrolled in Medicare due to age or disability
• 75 of Medicare enrollees under age 65

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More about WSHIP

• Individual premiums are
• 110 - 150 higher than comparable individual
  plans in the market (this is law)
• Not nearly high enough to pay the actual costs.
• The difference between premiums and total costs
  is made up through ASSESSMENTS

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How WSHIP is funded

• Because WSHIP premiums can be no higher than 150
  of comparable commercial plans
• And enrollees are the sickest and most costly
• Premiums paid by enrollees have averaged 32 of
  total costs of coverage over past five years
• The difference is paid by the carriers. They are
  ASSESSED their proportionate share of the cost
  based on their share of the general health
  insurance market in Washington state

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Funding continued

• Who gets assessed?
• Member Plans selling health insurance (group or
  individual). This includes all
• HMOs (Group Health)
• Service Contractors (Premera, Regence)
• Commercial Insurers (Aetna, United)
• Multi-employer Welfare (Timber Products)
• Stop-loss Carriers/UMP (Safeco, State plans)
• (Special deal ten cents on the dollar)
• Life, dental, long term care, disability income
  and Medicare Advantage coverage excluded.

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Funding continued

• WSHIP assessments become part of the premiums
  paid in the individual and group markets.
• Assessments in 2008 were about 40.7 million.
• This works out to be about 1.12 per month, for
  each person insured in the individual and group
  markets (roughly 3.6 million people).

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Funding continued

• WSHIP received federal grants to help cover
  losses and bonus grants to fund premium
  reductions
• In 2006 2.4 million (1.5m for operational
  losses the balance for premium subsidies)
• In 2008 1.6 million (1m for operational
  losses the balance for premium subsidies)

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Funding continued
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Funding study proposed

• 2009 Legislative proposal by WSHIP Board
• Solicit funds to study options for equitable,
  stable, and broad-based funding sources for the
  operation of the pool
• Report findings, recommendations appropriate
  legislative committees

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WSHIP Organization

• WSHIP Board of Directors
• Executive Director
• Benefit Management, Inc. (BMI) Plan
  Administration
• First Choice Health Network
• Medco (Pharmacy Benefit Manager)
• Qualis Health (Care Management)

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Application Process

• Person applies for private coverage
• Carrier application, along with the SHQ, are
  submitted to the carrier for scoring
• Carrier has 15 business days after receipt to
  process/score and send notice of rejection
• If carrier rejects, the rejection notice is sent
  to applicant along with a separate WSHIP
  application packet

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Carrier Rejection

• The only way to get WSHIP coverage is if a
  carrier first rejects the applicant

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WSHIP Enrollment Packet

• Application is 9 pages
• Section I Agent Information !!!
• Packet includes
• Eligibility information
• Summaries of Benefits (all plan options)
• Rate charts
• Low-income application
• Appeals Grievance Policy
• Online at www.wship.org

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WSHIP Non-Medicare Plans

• Standard Plan - 410 enrollees in 2008
• Deductibles 500, 1,000, or 1,500
• 80/20 coinsurance
• Three-tiered Rx copays, that vary with deductible
• Passive PPO overlay, First Choice Network (WA,
  OR, ID, MT Beechstreet nationally)

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Non-Medicare Plans (continued)

• Preferred Provider Plan - 2,034 enrollees
• Deductibles 500, 1000, 2500, 5000
• First Choice Health Network (WA, OR, ID, MT
  Beechstreet nationally)
• 80/20 network coinsurance 40 non-network
• Three-tiered Rx copays that vary with deductible

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Non-Medicare Plans (continued)

• HSA Qualified PPO Plan - 60 enrollees
• Deductible 3,000 (medical and Rx)
• 80/20 network coinsurance 40 non-network
• 20 Rx coinsurance
• Combined medical and Rx out-of-pocket expense
  limit (individual)
• 5,250 network 10,500 non-network

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Non-Medicare Plans (continued)

• Limited Preferred Provider Plan A 3 enrollees
• Deductible 1,500
• 80/20 network coinsurance 40 non-network
• Rx 50 non-preferred brand 30 brand 10
  generic copay Rx maximum 3,000/year
• Reduced benefits for
• medical supplies/equipment
• reduced visits/days for rehab therapies, skilled
  nursing facility, spinal manipulations.

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Non-Medicare Plans (continued)

• Limited Preferred Provider Plan B 11
  enrollees
• Deductible 1,500
• Coinsurance 20 network 40 non-network
• Rx 50 non-preferred brand 30 preferred brand
  10 generic copay Rx maximum 2,000/year
• Reduced benefits No maternity benefit
• reduced medical supplies/equipment allowance
• reduced visits/days for rehab therapies, skilled
  nursing facility, spinal manipulations.

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Theres really no need for confusion with this
Medicare stuff. Page 95, section 33, paragraph L
in the instructions quite clearly says
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Medicare Advantage Proposed Legislation

• Limit WSHIP enrollment for new Medicare-eligible
  persons to only those who do not have access to a
  reasonable choice of comprehensive Medicare Part
  C plans
• Must have access to at least three different HMO
  or PPO carriers in their county of residence
• Plan options must include coverage at least as
  comprehensive as a Plan F Medicare supplement
  plan combined with Parts A and B

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Medicare Advantage Proposed Legislation
(continued)

• Access to a stable provider network in place for
  at least two years
• Easily accessible provider directories either
  online or hard copy
• If no plan includes the provider from whom health
  care services were received in the past twelve
  months, not considered reasonable access

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Medicare Plans

• Medicare Basic Plan requires enrollment in
  Parts A B - 190 enrollees
• No deductible
• Secondary to Medicare Parts A B - acts as a
  Medicare wraparound
• No coinsurance for benefits covered by Medicare
• 20 coinsurance for other benefits
• Coverage for Part B Rx drugs no coverage for
  Part D Rx drugs

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Medicare Plans (continued)

• Medicare Basic Plus Plan 603 enrollees
• Closed to new enrollment.
• Must be enrolled in Medicare Parts A, B, and D.
• Pays 100 of deductible, copay, and coinsurance
  for Medicare benefits.
• Enrollee pays 20 of benefits not covered by
  Medicare.

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WSHIP Premiums

• By law, monthly premiums can be
• No higher than 150 of the comparable
  commercial plans, except
• Network Plan (PPO) can be no higher than 125 of
  the comparable commercial plans A, and
• NO premiums can be lower than 110

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2009 Non-Medicare Premiums

• Standard Plan base rates are 150 of the Standard
  Risk Rate (SRR)
• Preferred Provider Plan base rates are 110 of
  SRR with no additional discounts available
  (statutory minimum)
• lt65 age-rated in all plans by 5-year brackets
• Rates vary by plan and deductible choices
• Gender/smoking status do not apply

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2009 Non-Medicare Rate Examples

• Standard Plan (age 45)
• Base Rate
• 500 deductible 1,170
• 1000 deductible 1,009
• 1500 deductible 900
• With 18 months prior continuous coverage
• 500 deductible 975
• 1000 deductible 834
• 1500 deductible 750
• Rate Tables online at www.wship.org

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2009 Non-Medicare Rate Examples

• Preferred Provider Plan (age 45)
• 500 deductible 858
• 1000 deductible 740
• 2500 deductible 399
• 5000 deductible 315
• No additional discounts available for the PPO
  Plan
• At 110 of the Standard Risk Rate, the rates are
  as low as the law allows

53
2009 Non-Medicare Rate Examples

• HSA Qualified Preferred Provider Plan
• 3,000 deductible 382 (age 45)
• No additional discounts available for the PPO
  Plan
• At 110 of the Standard Risk Rate, the rates are
  as low as the law allows

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2009 Non-Medicare Rate Examples

• Limited Preferred Provider Plan A
• 1,500 deductible 618 (age 45)
• No additional discounts available for the PPO
  Plan
• At 110 of the Standard Risk Rate, the rates are
  as low as the law allows

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2009 Non-Medicare Rate Examples

• Limited Preferred Provider Plan B
• 1,500 deductible 552 (age 45)
• No additional discounts available for the PPO
  Plan
• At 110 of the Standard Risk Rate, the rates are
  as low as the law allows

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2009 Medicare Premiums

• 65 Basic Plan base rates are 150 of SRR
• 65Basic Plus Plan rates are 150 of SRR
• lt65 rates are 110 of SRR (based on Medicare
  disabled population)

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Medicare Plans 2009 Rate Examples

• Medicare Basic Plan
• age 45 195 age 65 293
• Medicare Basic Plus Plan
• age 45 323 age 65 487
• (additional discounts may apply for over age 65)

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WSHIP Premium Discounts

• Standard Plan Premium Discounts for Low Income
• Two levels, based on family income
• Greater than 250 to 301 of the Federal Poverty
  Level Guidelines
• Less than 251 of the Federal Poverty Level
  Guidelines
• Available ONLY if state funds for WSHIP are
  available.

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WSHIP Premium Discounts

• Additional Premium Discount for Standard Plan and
  Medicare over 65 if
• Have been enrolled in a prior plan for at least
  18 months (15)
• Have been enrolled in WSHIP for more than 36
  months (5)

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WSHIP Premium Discounts

• Combined Premium Discount on Standard Plan 1 and
  Over 65 Medicare for
• Coming onto a WSHIP plan with 18 months of prior
  continuous coverage AND
• Being enrolled in WSHIP for more than 36 months

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WSHIP Premium Discounts

• In No Case
• can the WSHIP premium
• be lower than 110 of the
• Standard Risk Rate
• (i.e., the rate for comparable plans)

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Why agents help needed

• Standard Health Questionnaire challenging!
• WSHIPs Application process can be confusing!
• People surveyed report difficulty in
  understanding both the SHQ and the application
  process.

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Agent Compensation

• Agents are paid 75 commission for each applicant
  accepted to WSHIP
• Copy of Agent License must be on file with WSHIP
  or included with application
• Page 1 of the WSHIP application must be included
  with the Agent name, signature and tax I.D. , W-9
  form (See next slide)

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(No Transcript)
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Final Details

• Any licensed agent can get paid by WSHIP

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This training gives you the opportunity to be
listed on the WSHIP Agent Directory

• Directory is posted on WSHIP website
• Downloaded 1,000 times in 2008
• Directory mailed out by carriers with WSHIP
  applications
• Receive quarterly WSHIP Agent Bulletin

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Agent Directory

• Complete and sign the listing form.
• Mail it to
• WSHIP
• PO Box 329
• Bow, WA 98232-0329
• Or fax to 360-734-2577 or email to
• Amackie_at_wship.org
• Include a copy of your Agent license.

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Agent Directory Listing Form

• I have completed the WSHIP agent training, and I
  would like to be listed as an agent for assisting
  WSHIP applicants.
• NAME____________________________________ License
  No.___________________
• FIRM______________________________________________
  ___________________
• ADDRESS___________________________________________
  __________________
• CITY________________________________ STATE ____
  ZIP ________________
• PHONE _________________________ FAX
  _________________________
• EMAIL _________________________
• SIGNATURE_________________________________________
  _ DATE ____________
• You must submit a copy of your agent license to
  WSHIP with this form
• Email to amackie_at_wship.org or mail to WSHIP, PO
  Box 329, Bow, WA 98232-0329

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• Questions?
• Contact WSHIP
• 360-734-2577