Utah Health Exchange 2.0 Ernie Sweat CEBS Salt Lake Luncheon

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Utah Health Exchange 2.0 Ernie Sweat CEBS Salt Lake Luncheon
Ernie Sweat CEBS
Utah Health Exchange Advisory Board

Limited to small employers (2-50)

One of two operational exchanges in the
country

Market Driven

Up to 114 plans available

Regence Blue Cross Blue Shield

United Healthcare

Select Health

Humana

Regence Blue Cross Blue Shield

United Healthcare

Select Health

Humana

$43/Subscriber
$37 to agent
$6 to administrators

Added to Raw Rates

Included for all enrollees (even without agent)
 Bswift
 Health
Equity

Prospective Risk Adjustment

Retrospective Risk Adjustment
 Employees Complete Universal Applications
 Two Carriers in Exchange are Randomly Selected
to Underwrite Risk
 Rateups are Assigned
 If Carriers are Within 30 points, the Average is
Assigned
 If Outside of 30 Points, a Third Carrier (mediator)
is Randomly Selected to Underwrite
 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
 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

All Premium is Pooled and then Allocated to
Carriers

New and Terminated Employees are Added
to/Subtracted from Algorithm

Average Score is Recalculated Monthly
 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

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
 Example:
Carrier A:
Carrier B:
$25,000 x 0.75 =
$80,000 x 0.75 =
Total:
$18,750
$60,000
$78,750
 Tally is Divided by the Membership of the
Exchange
Example:
15,000 Members = $5.25/Member
 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
 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

Access to Multiple Networks

No Minimum Contribution

Both Maternity and Non-Maternity plans may
be offered

No restriction on plan options

Exchange 1.0
Bswift
Health Equity

Exchange 2.0
Bswift
Health Equity
eHealthapp

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

Exchange 1.0
 Requires employer application
 Cumbersome excel spreadsheet
 Banking data required upfront
 Employee application via Bswift
 Data unavailable outside Exchange

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

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

Exchange 1.0
 Primary and Secondary Underwriter
 Primary Underwriter collects data via Bswift
 Secondary Underwriter and Mediator collect data
independently

Exchange 2.0
2 primary Underwriters
Each Underwriter receives data automatically
from eHealthapp
Mediator uses same process
Much faster turnaround




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


Employee data from enrollment forms sent to Bswift

Allows employees to have additional time to make
selections

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

Exchange 1.0
 Handled by Health Equity
 Funded by broker commission

Exchange 2.0
 Governed by the Utah Health Exchange
 Funded by carriers

Utilizes Calling Tree
 Bswift – Enrollment
 Health Equity – Billing
 eHealthapp – Group Enrollment
 Utah Insurance Department – Exchange Overview
 Carriers – Claims and specific questions

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

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

Quality and Cost Data on carriers and
providers
 Utilize Utah Health Information Network
 Mine feedback from consumers

Utilize Federal Funds
 Grants
 Vouchers

Integrate Medicaid
 Possible training for agents

Add the individual market
 Determine underwriting and risk adjustment
process
 Decide plan designs
▪ Likely that these will match the group market

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?

Addition of the larger employer sector
 Integration of 51-99 market
 Is there a place for 100+??
Ernie Sweat
801-814-4949
[email protected]

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