Obamacare in Washington

Health Insurance Marketplace in Washington

If you live in Washington, the Washington Healthplanfinder is the Health Insurance Marketplace to serve you. Instead of HealthCare.gov, you’ll use the Washington Healthplanfinder website to apply for coverage, compare plans, and enroll. Visit the Washington Healthplanfinder now to apply.

Spanish language speakers can contact cuidadodesalud.gov.

Choosing the Right Health Insurance Plan

There are a number of different tiers of plans available on the Washington Health Insurance Exchange. Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:

NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.

Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.

Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.

Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.

Washington health insurers don’t have to offer every tier of plan, but within the Washington health insurance exchange, all health insurance companies must offer at least one silver plan and one gold plan to consumers.

Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.

Expanded Medicaid

Washington will expand its Medicaid program in 2014 to cover households with incomes up to 133% of the federal poverty level. That works out to about $15,800 a year for 1 person or $32,500 for a family of 4. You can find out whether you qualify for Medicaid in Washington 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.

Who can help you?

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Information for:

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If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.

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Accountable Care Organizations in Washington

ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.

• Kitsap Mental Health Services WA – Health Care Innovation Award
• Prosser Public Hospital District WA – Health Care Innovation Award
• Northeastern University WA – Health Care Innovation Award
• Institute For Clinical Systems Improvement WA – Health Care Innovation Award
• Trustees Of Dartmouth College WA – Health Care Innovation Award
• University of New Mexico Health Sciences Center WA – Health Care Innovation Award
• University Of North Texas Health Science Center WA – Health Care Innovation Award
• State of Washington WA – Medicaid Emergency Psychiatric Demonstration
• State of Washington WA – State Innovation Models Initiative: Model Pre-Testing Awards

Health care facilities where Innovation Models are being tested

• Aging and Long Term Care of Eastern Washington Spokane, WA – Community-based Care Transitions Program
• Southeast Washington Aging and Long Term Care WA – Community-based Care Transitions Program
• Pierce County, Washington Community Connections’ Aging and Disability Resources WA – Community-based Care Transitions Program
• Whatcom Alliance for Healthcare Access WA – Community-based Care Transitions Program
• 112th Street Medical Clinic Everett, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Broadway Medical Clinic Everett, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Columbia Basin Health Association – Othello Family Clinic Othello, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Family Health Center North Beach Clinic Ocean Park, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• International Community Health Services – Holly Park Seattle, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Lynnwood Medical Clinic Lynnwood, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Neighborcare Health- 45th St Medical Clinic Seattle, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Neighborcare Health- Greenwood Medical Clinic Seattle, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Neighborcare Health- High Point Medical Clinic Seattle, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Neighborcare Health- Pike Market Medical Seattle, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Neighborcare Health- Rainier Beach Medical Clinic Seattle, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Neighborcare Health- Rainier Park Medical Clinic Seattle, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Sea Mar Marysville Marysville, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Sea Mar Mt. Vernon Mount Vernon, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Sea Mar Tacoma Tacoma, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Sea Mar Ocean Shores Ocean Shores, WA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Kellie Hamblin RN, BSN, MBA, CPHQ, SSGB Renton, WA – Innovation Advisors Program
• Christina Schwien MPH, MN, BS, BA Seattle, WA – Innovation Advisors Program

The Insurance Exchange/Marketplace

What has been done, not been done, or left up to the federal government to do.

Establishing the Exchange in Washington

On May 11, 2011, Governor Christine Gregoire (D) signed SB 5445 into law establishing the Washington Health Benefit Exchange (HBE).¹ Additional Exchange legislation signed by the Governor in March 2012, removed limitations on the Board’s governing authority over the Exchange (HB 2319).² In October 2012, the state announced that the online marketplace would be called Washington Healthplanfinder.

Structure: The legislation defines Washington’s Exchange as a quasi-governmental organization, specifically a “self-sustaining public-private partnership separate and distinct from the state.”

Governance: The Exchange is governed by an 11-member board, including two non-voting, ex officio members (or their designees): the Insurance Commissioner and the Administrator of the Health Care Authority. The Governor will appoint eight voting board members from lists of nominees created by the two largest caucuses in the House and Senate. The legislation specifies that appointees must include at least one employee benefits specialist, one health economist or actuary, one representative of small business, and one health consumer advocate. The remaining voting members should possess related expertise in areas such as individual or small employer health care coverage, health benefit plan administration, or health care finance. The Governor will appoint a ninth member to the Board who will serve as chair and vote only when needed in case of a tie. Voting board members cannot be legislators or employees of the state or its political subdivisions. The Governor cannot appoint members whose participation in Board decisions would benefit their own financial interests or those they represent. Members developing these conflicts of interest should resign or be removed from the Board.

Current appointed Board members are:

• Margaret Stanley (Chair), formerly with Puget Sound Health Alliance and Regence Blue Shield
• Steve Appel, farmer and formerly with Washington Farm Bureau
• Bill Baldwin, The Partners Group
• Don Conant, Valley Nut and Bolt and School of Business at St. Martin’s University
• Doug Conrad, University of Washington School of Public Health
• Melanie Curtice, Stoel Rives LLP
• Ben Danielson, MD, Odessa Brown Children’s Clinic
• Phil Dyer, Kibble & Prentice/USI and former state legislator
• Teresa Mosqueda, Washington State Labor Council and Healthy Washington Coalition

The Board held their first meeting in early January and assumed governing authority over the Exchange on March 15, 2012. A few months later the Board hired a CEO.

Exchange legislation specifies the Board should establish advisory committees to represent the views of the health care industry and other stakeholders, and may also establish technical advisory committees or seek advice of technical experts. In addition, it requires the Exchange to consult with the American Indian Health Commission. In May 2012, the Board selected 17 Advisory Committee members to provide expertise and experience on various issues. Members include carriers, brokers, small employers, consumer advocates, a Tribal representative, and providers.³

The Washington Health Care Authority assisted the Board in establishing HBE and was responsible for providing staff, resources, managing grants and other funds appropriated by the Legislature.  While HBE is now an independent organization, it continues to work closely with the Health Care Authority and other state agency partners, including the Office of the Insurance Commissioner (OIC) and the Department of Social and Health Services (DSHS). The Exchange Board, the Insurance Commissioner, and the Washington Health Care Authority are all responsible for continuing to move Exchange implementation forward on an aggressive timetable. The Exchange Board has a policy decision timeline outlining when key decisions should be made.⁴

Contracting with Plans: In early 2012, the Exchange formed a Plan Management Workgroup which includes representatives of the health insurance industry to provide input on how to offer individual and small group plans in the Exchange. In June 2012, the Board approved 19 criteria (all of which were specified in the ACA) to be the framework for health insurers’ participation in the Exchange.⁵ The OIC is responsible for reviewing nine criteria while the HBE will review the remaining ten. In February 2013, HBE released guidance that further details requirements for QHP participation in Healthplanfinder.⁶

The Exchange intends to allow all qualified health plans (QHPs) meeting the minimum standards to participate in the Exchange in 2014. HB 2319 created new insurance market rules for plans sold inside and outside Healthplanfinder. If an insurer offers a bronze plan in the individual or small group markets outside the Exchange, it must also offer plans in the silver and gold levels for that same market. Catastrophic plans may only be sold inside of the Exchange. Issuers may participate in Healthplanfinder’s individual market, SHOP market, or both and are not required to participate in the same markets inside and outside of the Exchange. Issuers must offer at least one QHP at the silver level and one QHP at the gold level in order to participate in Healthplanfinder. Issuers are also required to offer a child-only plan at the same level of coverage as any QHP offered through Healthplanfinder. The OIC requires issuers to offer contracts to all Indian Health centers in their service area, and issuers must notify HBE of all such contracts.

Nine issuers filed with the OIC to provide a total of 57 proposed QHPs on the individual market, including four catastrophic plans.⁷ No platinum level plans were proposed for either market. OIC will review the plans to ensure their compliance with the ACA’s essential health benefits requirement and other state and regulatory requirements.  HBE intends to conduct final certification of QHPs for 2014 during Board meetings in July and August of 2013. HBE will certify QHPs annually and issuers will offer QHPs for a term of one year. QHP issuers must also sign a participation agreement with HBE in order to participate in Healthplanfinder. A draft participation agreement was released in May 2013 and issuers are expected to submit signed participation agreements to HBE by mid-July.⁶

HB 2319 required that by the end of 2012, the Board establish a rating system for qualified health plans to assist consumers in evaluating plan choices.  In September 2012, the Board approved nine consumer rating factors and the use of specific corresponding data sources including the Consumer Assessment of Healthcare Providers and Systems (CAHPS) data for enrollee satisfaction and Healthcare Effectiveness Data and Information Set (HEDIS) data for provider reimbursement and promotion of primary care.⁸ QHP issuers must also document implementation of quality improvement strategies outlined by the Affordable Care Act (ACA), and submitted strategies will be posted online for consumers to review.

Issuers must ensure that each QHP’s network is sufficient in the number and type of providers, including mental health and substance abuse specialists. The network must also satisfy the essential community providers standard outlined by the ACA and comply with the provisions set forth by the Public Health Service Act and Washington Administrative Code 284-43-200. QHP issuers may only contract with hospitals with more than 50 beds if the hospital has a patient safety evaluation system in place. The OIC will monitor compliance of network adequacy requirements and HBE will decertify QHPs of issuers that do not adhere to the standards. Issuers must also submit health care provider data to HBE for a network directory.

Rates will differ based on QHP service area, which will be determined by county. Consumers will be able to locate their service area and view premium rates by entering their zip code into Healthplanfinder. The OIC requires QHP issuers to provide justification for premium increases and will post justifications online for the public.

HBE will aggregate subscriber premiums and send the aggregated payments to the appropriate issuer. Subscribers enrolled in the individual market will also be allowed to pay premiums directly to the issuer.

Dental and Vision Benefits: A Technical Advisory Committee (TAC) for dental plans began meeting in June 2012 to provide professional perspective on dental issues and make recommendations to the Board. Due to existing state law requiring dental benefits to be offered and priced separately in the Exchange, Washington has had to evaluate how to best operationalize its offerings of dental benefits in the Exchange, while also adhering to existing federal requirements around pediatric dental as an essential health benefit required as part of all Exchange plans.^{9 10} The Dental TAC also held multiple meetings to develop Qualified Dental Plan (QDP) certification standards.¹¹ In March 2013, HBE issued final guidance for participation of stand-alone pediatric dental plans in Healthplanfinder. Six issuers intend to offer dental plans. The Board expects to perform final certification of QDPs at their July and August meetings.¹²

Risk adjustment, Reinsurance, and Risk corridors (RRR): In a presentation to the Exchange Board in September 2012, the Office of the Insurance Commissioner’s Workgroup on RRR expressed a preference for state operated risk adjustment programs.¹³ The OIC will monitor issuer compliance with the risk adjustment program; if the OIC determines that an issuer is not in compliance with program requirements, HBE will decertify all of the issuer’s QHPs.

Consumer Assistance and Outreach: In January 2013, the Board approved a proposal establishing a Navigator program comprised of Lead Organizations, organized by county service area or target population, that will contract with HBE to build, train, fund, and monitor networks of in-person assisters (IPAs) and Navigators.¹⁴  IPAs and Navigators will perform the same services, including providing enrollment assistance, conducting community outreach, and maintaining ongoing relationships with consumers. HBE allocated $6 million of an Establishment grant for IPA Lead Organization contracts. IPAs will be phased out of the Navigator program in 2015. In March 2013, HBE issued a Request for Proposals for IPA Lead Organizations and applications were due April 22.  HBE received 19 proposals and grant awardees will be announced in late May.¹⁵  An RFP for tribal assister services was released on April 5, 2013; responses are due by June 28.¹⁶

While seven carriers initially submitted letters of intent to participate in the SHOP, most have since withdrawn due to concerns about operational readiness and risk. One carrier has indicated it will participate; however, it serves only five counties.¹⁹ In May 2013, the Board voted to launch the SHOP on October 1, 2013, despite the limited carrier participation.²⁰

Information Technology (IT): Development of the Exchange’s IT infrastructure has been led by the Washington Health Care Authority. IT plans include designing a system with a single point of entry for state health insurance programs that uses shared eligibility services for tax credits through the Exchange and Medicaid/CHIP, similar enrollment functions and some shared administrative functions. The Washington Health Care Authority secured a subcontractor in February 2012 to build an IT system integrator which would determine eligibility for Medicaid, CHIP, and the Exchange.²¹ The first seven deliverables have been built including functionalities for plan management, SHOP Employer functionality, SHOP employee enrollment, Individual eligibility and enrollment, financial management, and administrative functionality.^{22 23} The Exchange system will interface with the Medicaid systems (Provider One and ACES) to determine eligibility. Integration of the systems is underway and expected to be fully functional for the open enrollment period.²⁴ The state has received approval from the Centers for Medicare and Medicaid Services (CMS) for enhanced funding to upgrade Medicaid eligibility and enrollment systems.

In June 2012, the Exchange Board approved a requirement that the Exchange IT system design and build include the capability of the Exchange to aggregate premiums.

In February 2013, Washington was one of two states selected by the Center for Consumer Information and Insurance Oversight (CCIIO) for a first wave of information technology system testing conducted by the federal government. Testing began in April and is intended to assess the infrastructure behind Healthplanfinder as well as its ability to integrate with federal data systems.²⁵

Financing: The Exchange Board is required to develop a methodology by the end of 2012 to ensure the Exchange is self-sustaining after 2014. HB 2319 gives the Board explicit authority to assess a surcharge on premiums. The Exchange is required to be self-sustaining without direct state tax subsidies, or else operations can be suspended. The Exchange Operations Committee evaluated options for Exchange financing including, requiring an assessment on qualified health plans based on either total membership or Exchange membership, imposing a new tax on hospital revenue, and/or charging a user fee for Exchange members or employers.²⁶ After multiple meetings discussing self-sustainability around revenue models, the Board’s draft recommendation to the legislature was a 0.5% premium tax effective January 1, 2014 on all premiums and prepayment for health care services received. Then beginning January 1, 2015, the premium assessment would rise to 1.0%.²⁷ Legislation to establish a financing mechanism for HBE (ESHB 1947) is currently being considered by the House and Senate. The bill reflects the Board’s recommendation.²⁸

Basic Health Program (BHP) Option: Washington has considered establishing an optional bridge program available through the Affordable Care Act (ACA) which allows states to use federal funding to offer subsidized health insurance to adults with incomes between 139 and 200% of the federal poverty level (FPL) who would otherwise be eligible to purchase subsidized coverage through an Exchange. The state released a proposal in June 2012 to operationalize a BHP, but awaits final approval from the federal government.²⁹ Washington already operates the Washington Basic Health program, a state-sponsored program that provides low-income residents below 200% FPL with health care coverage through private health plans; however, this program would have to be modified to meet federal criteria for a BHP.³⁰ The Washington Health Care Authority was required to submit a report to the Legislature on whether to proceed with implementation of a federal Basic Health Plan Option by the end of 2012.

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. The state recommended the EHB benchmark be Blue Shield- Regence Innova Plan PPO.³¹ In addition, the Children’s Health Insurance Program (CHIP) will serve as the pediatric dental supplement, and the Federal Employee Vision Plan (FEDVIP) as the pediatric vision supplement. The Insurance Commissioner is required to submit annually to the Legislature a list of state-mandated benefits, the costs of which will be borne by the state.

 Exchange Funding

The Washington Health Care Authority has received two federal grants: the Exchange Planning grant of almost $1 million and the Level One Establishment grant of approximately $23 million to be used for operational planning and to develop an information technology system for critical Exchange functions related to eligibility, enrollment and information exchange.³² In May 2012, the state was awarded a $127.8 million Level Two Establishment grant to fund Exchange development through December 2014.³³

Expansion of Medicaid

From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.

As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.

However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.

Washington is participating in Medicaid expansion.

 Next Steps

On December 7, 2012, Washington received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based exchange.³⁴ Final approval is contingent upon the state demonstrating its ability to perform all required Exchange activities on time and complying with future guidance and regulations.

Additional information about the Washington Health Benefit Exchange can be found at: http://wahbexchange.org/

Also of interest