Obamacare in West Virginia

Health Insurance Marketplace in West Virginia

If you live in West Virginia, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll.

Spanish language speakers can contact cuidadodesalud.gov.

Choosing the Right Health Insurance Plan

There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.

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.

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

West Virginia 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 West Virginia 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 (the Navigators)

Get local help

Advanced Patient Advocacy, LLC

For nearly 14 years, Advanced Patient Advocacy has partnered with health care providers and state and local governments in 21 states to provide services to communities to help educate and enroll uninsured consumers. Advanced Patient Advocacy will work with medical centers to identify uninsured individuals and provide education and assistance to help them make informed decisions about enrollment in the Marketplaces.

West Virginia Parent Training and Information, Inc.

West Virginia Parent Training and Information, Inc. will provide public education about health insurance options, and facilitate enrollment in the new health insurance marketplaces. The effort will include outreach to people with disabilities, people with limited English proficiency and/or limited literacy, people of low socioeconomic status, and people in rural areas.

Information for:

Individuals and Families

Small businesses

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 West Virginia

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.

• TransforMED WV – Health Care Innovation Award
• Duke University WV – Health Care Innovation Award
• State of West Virginia WV – Medicaid Emergency Psychiatric Demonstration

Health care facilities where Innovation Models are being tested

• AmediAmedisys Home Health of West Virginia Charleston, WV – BCPI Initiative: Model 3
• Amedisys Home Health of West Virginia Parkersburg, WV – BCPI Initiative: Model 3
• Amedisys Home Health of West Virginia Beckley, WV – BCPI Initiative: Model 3
• New River Health – North Fayette Family Health Center Fayetteville, WV – Community-based Care Transition Program
• AccessHealth Glen Daniel Glen Daniel, WV – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• New River Health – Gulf Family Practice Sophia, WV – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Valley Health Westmoreland Huntington, WV – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Valley Health Fort Gay Fort Gay, WV – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Preston-Taylor Community Health Centers dba Eglon Clinic Eglon, WV – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Preston-Taylor Community Health Centers dba Medical Center of Taylor County Grafton, WV – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Tri-County Health Clinic/CCWV Rock Cave Rock Cave, WV – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Valley Health Care Mill Creek, WV – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Valley Health Harts Harts, WV – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Valley Health Huntington Huntington, WV – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Valley Health Stepptown Kermit, WV – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Valley Health Wayne Wayne, WV – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• Valley Health Upper Kanawha Medical Cedar Grove, WV – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
• WomenCare Women’s Health & Birth Center Hurricane, WV –  Strong Start for Mothers and Newborns Initiative

The Insurance Exchange/Marketplace

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

Establishing the Exchange in West Virginia

On February 15, 2013, Governor Earl Ray Tomblin (D) submitted a blueprint to Secretary Sebelius for West Virginia to establish a state-partnership exchange with plan management responsibilities.¹ In the previous year, Governor Tomblin had signed SB 408 into law to establish the West Virginia Health Benefits Exchange and the state had begun exploring implementation options for a state-based exchange.² However, concerns over the sustainability of a state-run exchange led the Governor to pursue a partnership exchange instead.

Prior to the decision to pursue a partnership exchange, the Health Policy Division, within the Office of the Insurance Commissioner (OIC), led the exchange planning initiative. In January 2012, the OIC released a business plan which documented an approach to implementing the Exchange.³ In addition, the OIC held a series of public engagement meetings throughout the state and met regularly with stakeholder groups to focus on exchange implementation issues related to carriers, consumers, producers, and providers.

Contracting with Plans: In April, 2013 the West Virginia Offices of the Insurance Commissioner (OIC) released a Qualified Health Plan Submission Guide to provide guidance to health insurance issuers regarding the certification standards for individual and SHOP Qualified Health Plans (QHPs) offered through the Exchange. OIC expects issuers to submit QHPs April 1 – May 31 of 2013, and will review submissions and recommend QHPs to the Department of Health and Human Services (HHS) April 1 – July 31 of 2013. OIC expects issuers to enter into certification agreements with HHS in August 2013.

Rates may vary based on tobacco use, family composition, age, and geography. West Virginia will use eleven geographic rating areas. Issuers must submit rate information to the Exchange on an annual basis, and the OIC will review rates for compliance with rating standards.⁴

Acting as a clearinghouse, OIC will accept plans that meet federal and state certification criteria. The State has partnered with the West Virginia School of Osteopathic Medicine to develop a strategy to maximize and report on provider quality in the Exchange, such as through measurement and reporting, purchasing, and engaging consumers through better information.

Risk Adjustment, Reinsurance, and Risk Corridors: In 2011, the West Virginia legislature passed HB 2745 to develop an all-payer claims database and the state expects to begin collecting data in 2013.⁵ This database will provide the baseline information to create a risk adjustment program, as well as to provide outcome quality data and enable analyses of exchange policy initiatives. Governor Tomblin noted in his letter of intent to establish a state-partnership exchange that West Virginia does not intend to operate a reinsurance program in 2014.⁶

Consumer Assistance and Outreach: The federal government will administer the state’s Navigator program, while the West Virginia OIC will oversee an In-Person-Assister (IPA) program.¹ CMS has allocated $600,000 for the Navigator program in West Virginia.⁷ Navigator entity applications were due on June 7, 2013 and grantees will be notified by the federal government on August 15.⁸

The state selected an In-Person Technical Assistance contractor in July 2013 to help select IPA entities that will operate around the state.⁹ IPAs will focus on assisting vulnerable and underserved populations in the individual private and public markets. They will likely receive training in the small group market as well, to assist individuals that do not have an agent-consumer relationship. The state plans to have IPAs meet the same training, privacy and security, and conflict of interest standards as outlined in federal guidance on Navigators. The state currently estimates a need of 270 IPAs during open enrollment, and approximately 30 IPAs during non-peak periods. IPA entities will be selected in June and trained and certified in August of 2013. Outreach efforts will be conducted in August-September 2013. West Virginia will rely on the federal government for mass marketing and branding of the marketplace. The IPA vendor may perform some marketing at the local level.¹⁰

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. Since West Virginia did not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Highmark (Blue Cross Blue Shield of West Virginia)- Super Blue Plus 2000 PPO.

Exchange Funding

The West Virginia Office of the Insurance Commissioner received a federal Exchange Planning grant of $1 million in September 2010 and a federal Level One Establishment grant of $9.7 million in August 2011. The Establishment grant will be used to study consumer quality and effectiveness, complete economic modeling, and investigate risk adjustment strategies and policy integration with state agencies.In July 2013, West Virginia received a second Level One Establishment grant for $10.2 million to support the IPA program and plan management activities.¹¹ The state requested and received a No Cost Extension for the Establishment grant, in part due to the delay of the release of an RFP for an actuarial assessment and economic model of the Exchange.¹²

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.

West Virginia will participate in Medicaid expansion.

Next Steps

On March 5, 2013, West Virginia received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-partnership exchange.¹³ 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 West Virginia Exchange can be found at: http://healthbenefitexchangewv.com

Footnotes

Also of interest

Provided by the Henry J. Kaiser Family Foundation