Lawmakers grapple over exchange funding
Washington Senate Bill 6089 moved quickly through the state Senate this spring, and is currently in the House. Introduced by Senator Andy Hill (R – 45th District), the bill not only cuts funding for the exchange in the state budget, it would also prohibit the exchange from receiving any of the state taxes collected on health insurance plans (currently 2 percent of premiums, and that money would be sent to the state general fund instead of to the exchange), and it would also bar the exchange from getting reimbursement for outreach activities, even if federal funds were to be available to reimburse exchanges.
If the bill were to pass, it would essentially limit exchange funding to the carrier assessment, currently set at $4.19 per member per month. It’s estimated that amount would have to quadruple in order to make up for the budget cuts included in SB6089 – but even if that were to happen, the exchange wouldn’t be able to access all of that funding, because it would exceed the funding limits set in the current statutes. SB6089 passed the Senate on a party line vote, and although the Senate has a slight Republican majority, Democrats have a slim majority (51 – 47) in the House of Representatives. It’s thus unlikely that SB6089 will pass as-is, but given the disagreement, it’s unclear how exchange funding will fare in the 2016 fiscal year budget.
Open enrollment for 2015 – including the two-month special enrollment period that was added this spring – has ended in Washington. In order to purchase individual health insurance (including outside the exchange) for the rest of the year, you’ll need to have a qualifying event.
Total enrollment through Washington Healthplanfinder amounted to nearly a million people by the end of open enrollment, including 818,697 Medicaid enrollments.
On April 22, Washington Healthplanfinder announced that total private plan enrollment for 2015 had reached 170,101 people. This is the third-highest total (behind California and New York) of any of the state-run exchanges. All of these enrollees have paid for their coverage; Washington only reports enrollments if they’re paid up. In most states, the paid enrollment number is about 88 percent of the total plan selections, so it’s likely that there were several thousand additional enrollments that were finalized but hadn’t yet been paid for at that point. Washington’s approach totally eliminates critics’ “how many have paid?!” concerns.
Of the total private plan enrollments, more than 16,000 had enrolled during the spring special enrollment period that Washington Healthplanfinder offered for people who weren’t able to finish their enrollment by February 15, as well as people who were unaware prior to filing their taxes that the ACA includes a penalty for being uninsured. The special enrollment period ran from February 17 to April 17 in order to cover the whole tax filing season.
As of February 21, nearly 88 percent of Washington Healthplanfinder’s private plan enrollees were receiving premium subsidies. In 2014, the exchange reported that premium subsidies averaged $390/month per family, and amounted to a total of $334 million across all enrollees for the year. Because Washington established its own state-run exchange, subsidies there do not hinge on the outcome of the King v. Burwell Supreme Court case.
75 percent of 2014 enrollees renewed for 2015
On December 31, total enrollment had stood at 107,071. Of those enrollees, 27,753 were new to the exchange for 2015. The rest had a plan in 2014 and either renewed it or selected a different exchange plan for 2015.
That means about 60 percent of Washington Healthplanfinder’s 130,000 enrollees from 2014 had returned to the exchange to manually renew or make changes to their existing coverage before the end of December. Richard Onizuka, the exchange director, noted in December that while many of those who had not returned to the exchange had unpaid balances on their account from 2014, that is “not a barrier to enrollment in 2015.” If your coverage lapsed in 2014 because you didn’t pay the premiums, you can still come back during open enrollment and sign up for 2015 (this is a provision of the ACA, and applies in every state).
Although automatic renewal was possible through Washington Healthplanfinder, the exchange encouraged the rest of their 2014 enrollees to log back onto the exchange site or use the call center for assistance in updating financial information and confirming a plan selection for 2015. As of March 26, nearly 67,000 of Washington Healthplanfinder’s 2015 enrollees were new to the exchange, while the rest already had exchange coverage in 2014. At that point, total private plan enrollments stood at about 165,000 people, so roughly 98,000 of them were returning customers from 2014 – about 75 percent of the 130,000 enrollees from 2014.
Another 170k enrolled off-exchange
In addition to the 170,000 people enrolled in exchange plans in Washington for 2015, another 170,000 enrolled in private plans outside the exchange. While those plans are not eligible for premium subsidies, they’re fully compliant with the ACA’s regulations – they cover all of the essential health benefits, are guaranteed issue (no medical underwriting), and have no lifetime or annual limits on coverage.
Renewing coverage for 2015
For people who already had a plan through Washington Healthplanfinder, automatic renewal was possible – assuming their plan is still available in 2015 – if they checked a box on their initial 2014 application allowing the exchange to verify their subsidy eligibility by checking federal tax data for up to five years. About 80 percent of the exchange’s 2014 plans are available again in 2015, and the exchange reported in October that roughly 100,000 of their private plan enrollees would be eligible for automatic renewal.
These consumers received a letter from the exchange letting them know that their plan was being renewed with the applicable subsidy, but they also had the option to switch to a new plan during open enrollment. In Washington, the deadline to enroll or switch plans was December 23 if you want to have a January 1 effective date (this is later than the deadline in most other states, and the exchange also granted a 60 day special enrollment period to people who started their enrollment or renewal by December 23 but were unable to finish it because of technical difficulties).
Even though automatic renewal was possible for most Washington Healthplanfinder enrollees, it was probably not the best option for most people. The benchmark plan (second-lowest-cost silver plan) decreased in price in most of Washington state for 2015. Enrollees who kept the benchmark plan from last year saw rate increases that range from an average of 2 percent to nearly 11 percent, depending on where they live. But enrollees who shopped around and switch to the new benchmark plan could see significant rate decreases instead.
2015 rate hike less than 2 percent
Washington Insurance Commissioner Mike Kreidler announced in September that for plans sold through Washington Healthplanfinder average premiums would only be increasing by 1.9 percent for 2015. This represents a significant improvement over the past several years, when premiums in the individual market in Washington increased an average of 8 to 18 percent each year.
In addition to lower-than-normal rate increases, 90 plans are available in 2015 from the ten carriers in the exchange (plan availability varies from one region to another). That’s nearly double the 46 individual policy options that were available in 2014.
Once open enrollment began on November 15, residents were able to easily compare rates and plans in the site’s plan browsing section. It takes less than a minute on the exchange’s shopping system to see quotes with estimated subsidies included.
Billing and invoices – problems and solutions
In Washington, enrollees currently pay their premiums directly to Washington Healthplanfinder and the exchange then sends the premiums out to each insurer (although the exchange notes that customers do also have the option of paying premiums directly to insurers). This is different from the standard billing method used in most other states, where insureds pay their premiums to the carriers after enrolling through the exchange.
For the most part, this has worked smoothly in Washington, but a technological invoice problem impacted roughly 25,000 enrollments (about 15 percent of the total) and has resulted in premiums being paid even though the carrier has no record of the enrollee.
By early October, according to the exchange, nearly all of the billing problems had been resolved, but there were still approximately 1,300 customer accounts that continued to have technical issues. By the time the 2015 open enrollment began in mid-November, the exchange reported that lingering billing problems from 2014 were still affecting about a thousand customers.
But health insurance carriers had a different story to tell. As of October 30, Premera Blue Cross Blue Shield had 15,000 members whose coverage was in limbo because of billing problems with Washington Healthplanfinder. And the Association of Washington Healthcare Plans estimated that the problems were still impacting about 25,000 insureds state-wide at the end of October.
Because of the billing problems that have plagued the exchange, the board voted 4-3 in mid-December to remove the exchange from the invoicing/payment collections part of the process, and turn it over to the insurance carriers, the way it’s done in most other states. There was much debate on whether that was the best course of action or not, but ultimately it was decided that carriers will take over the billing process in the fall of 2015, in time for the 2016 open enrollment period.
But although there have been glitches with private plan enrollment in the exchange, Medicaid enrollment and renewal has been very smooth. In December, the exchange auto-renewed about 150,000 Medicaid enrollments. This is an ongoing process, because Medicaid enrollment is year-round and thus renewals come up every month.
An early glitch, quickly resolved
Officials at Washington Healthplanfinder learned in 2014 that enrollment errors are difficult to fix once the enrollment is finalized. So when they discovered that the exchange had a slight error in calculating tax credits in the early hours of 2015 open enrollment, they made the decision to shut down the exchange temporarily while they sorted out the issue, viewing this as preferable to letting people continue to enroll with incorrect premium subsidies.
The error was a result of the system still using data from the first open enrollment, instead of updated numbers. Poverty level tables from 2013 were used for people enrolling in 2014 plans, but now that we’re enrolling for 2015, it’s the 2014 poverty level tables that are being used. And the applicable percentage of income that you have to pay for the second-lowest-cost silver plan has been updated for 2015 as well.
About 150 enrollees had finished their application and scheduled premium payments based on the incorrect subsidy amounts before the glitch was noticed, and Washington Healthplanfinder reached out to all of them to fix the problem. The exchange shut down within hours of opening on November 15, but was back up and running by the next morning and has been functional ever since.
New carriers, more plans
In 2014, eight insurers offered individual policies through the Washington Healthplanfinder. That has grown to ten carriers for 2015 (Columbia United Providers and Moda Health Plan are new to the exchange for 2015):
- Columbia United Providers
- Community Health Plan of Washington
- Coordinated Care
- Group Health Cooperative
- Kaiser Foundation Health Plan of the Northwest
- Moda Health Plan Inc.
- Molina Healthcare of Washington
- Premera Blue Cross
Not all carriers offer plans in all areas of the state. Only Lifewise and Moda offer policies in all 39 counties in Washington, and Premera offers policies in 38 counties (all but Clark). The rest of the carriers offer plans in selected areas ranging from a single county to 19 counties.
The addition of more carriers and plans demonstrates how successful Washington’s exchange has been in its first year, and the new plans should be beneficial in terms of competition, consumer choice, and rate stabilization.
Improvements for 2015
Open enrollment for 2015 started on November 15. It ran for just three months this time, ending on February 15, and Washington Healthplanfinder CEO Richard Onizuka reminded Washington residents to enroll early rather than waiting until the last minute.
Washington Healthplanfinder was hard at work in 2014 to ensure that their second open enrollment period would be even more smooth and successful than their first. The exchange made significant progress on the back-end functionality of the website, improved the transmittal of enrollment and payment data to insurance carriers, and implemented critical code and data fixes to avoid repeats of the isolated – but very frustrating – billing and invoice issues that arose in 2014. As a result of all the fixes, it was expected that there would be far fewer billing, enrollment, and submission errors during the 2015 open enrollment.
From a consumer interface perspective, Washington Healthplanfinder is more user friendly this year too. They’ve added screen-sharing functionality with customer support, and additional on-screen definitions to help consumers – especially those who are not familiar with how health insurance works – better understand the enrollment process.
They’ve also added new information on the eligibility screen to make it easier to understand eligibility for each member of a household. This page summarizes the improvements Washington Healthplanfinder has made over the last year.
Consumers also have the option to pay premiums to the exchange using paper checks in 2015, as opposed to 2014 when all payments had to be electronic. Although electronic payments are widely considered to be a convenient method, they can be difficult for low-income residents.
The Washington Healthplanfinder tripled its call center staffing to 500 people during open enrollment, and there are also 2,500 brokers in Washington who are certified to help customers enroll in a plan through the exchange.
Washington Healthplanfinder 2014 enrollment
Washington Healthplanfinder announced on September 5 that 147,888 people were enrolled in private plans through the exchange as of the end of July. The exchange had enrolled 11,497 people with special enrollment periods triggered by qualifying events since between March 31 and July 31, and remains one of the country’s most successful exchanges. A quarter of the people who enrolled were in the 25 – 34 “young invincible” age group.
By the end of July, the exchange had disenrolled a total of 24,072 people because of non-payment, loss of eligibility, or voluntary plan terminations, but that’s an attrition rate of just 6.4 percent. Including Medicaid and private plans, 1,283,670 people were enrolled in plans through Washington Healthplanfinder at the end of July.
As of October, 139,700 people were enrolled in private plans through Washington Healthplanfinder, indicating that their rate of enrollment due to qualifying events had continued at roughly the same pace throughout the summer and fall.
In addition to the private plan enrollments, 909,752 people had enrolled in Medicaid through the Washington exchange by mid-April (nearly half of those people were already enrolled previously, but renewed their Medicaid coverage through the exchange).
Also by June 1, another 171,286 people had enrolled in private individual plans outside of the exchange in Washington, making the off-exchange market in Washington even more robust than the exchange market (off-exchange plans are all ACA-compliant, but there are no subsidies available to offset the premiums and cost-sharing for off-exchange plans).
Special off-exchange enrollment period
With all of the improvements, the state Insurance Commissioner Mike Kreidler said he was “cautiously optimistic” that the technological problems people have faced with enrollment this year would be fully resolved by November 15 (the problems do appear to be fixed, other than the subsidy calculation error that resulted in one day of downtime for the exchange at the start of open enrollment).
Because of the glitches that hampered enrollment for some people in 2014, Kreidler’s office implemented a special open enrollment period running from August 27 to November 14, for people who wanted to enroll in a plan outside the exchange because of problems with their exchange enrollment. Subsidies are not available outside the exchange though.
Washington Heatlthplanfinder history
Washington was one of the first states to move ahead with a state-run health insurance marketplace as envisioned by the Affordable Care Act. Former Gov. Chris Gregoire signed legislation creating the state exchange in May 2011. In March 2012 Gregoire signed additional legislation, which further defined how the exchange will be governed and operated.
The Washington Health Care Authority (HCA) helped establish the Washington marketplace. HCA transitioned governing authority to an 11-member board of directors in March 2012. The governor appointed eight voting members and a board chairperson who votes only in if needed to break a tie. In addition, the insurance commissioner and the administrator of the Health Care Authority are non-voting members.
In March, 2014, Washington legislators tried to pass a bill that would have created much more transparency in the state’s health insurance industry, providing consumers with data on how much insurers are paying for services in each region of the state. It had widespread support, but opposition from Premera Blue Cross – the state’s largest insurer – sank the bill and Washington did not join the 11 other states that have all-payer claims databases.
The federal government is funding the Washington Healthplanfinder in 2014. In 2015, marketplace operations will be funded by the state with $21 million that was previously earmarked for the state’s high-risk insurance pool, which will be operated through the exchange, and with a 2 percent tax on premiums on plans sold through the exchange.
According to the U.S. Department of Health and Human Services (HHS), about 835,000 Washington residents could potentially use the new marketplace to purchase private plans (nearly 148.000 had done so by the end of July). The Washington insurance commissioner’s office estimates that 477,400 residents will qualify for subsidies, and state set a target of enrolling 280,000 people in 2014. Obviously it fell short of that amount, but enrollment continues throughout 2014 as a result of qualifying events.
Healthplanfinder Business (SHOP)
The Washington exchange for small businesses is offering 23 plans from two carriers in 2015:
- Moda Health Plan is available state-wide, and is new to the small business exchange.
- Kaiser Permanent is available in Clark and Cowlitz counties, where it also offered small group plans in 2014.
No grandmothered plans
Washington Insurance Commissioner Mike Kreidler and Governor Jay Inslee took a strong progressive stance with regards to consumer protections: existing plans that did not meet ACA standards were cancelled at the end of 2013 and needed to be replaced on January 1 with new, ACA-compliant policies. Following President Obama’s announcement that carriers could extend existing plans into 2014 if states allowed it, Kreidler and Inslee were quick to declare that Washington would not allow non-compliant plans to continue into 2014.
Contact the Washington exchange
More Washington State health insurance exchange links
Washington Health Benefit Exchange
Information about marketplace planning and development
State Exchange Profile: Washington
The Henry J. Kaiser Family Foundation overview of Washington’s progress toward creating a state health insurance exchange.