State Marketplace Profiles: Washington
Updated as of October 22, 2013
Establishing the Marketplace
On May 11, 2011, Governor Christine Gregoire (D) signed SB 5445 into law establishing the Washington Health Benefit Exchange (HBE).1 Additional legislation signed by the Governor in March 2012, removed limitations on the Board’s governing authority over the Marketplace (HB 2319).2 In October 2012, the state announced that the online Marketplace would be called Washington Healthplanfinder.
Structure: The legislation defines Washington’s Marketplace as a quasi-governmental organization, specifically a “self-sustaining public-private partnership separate and distinct from the state.”
Governance: The Marketplace 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 appoints 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 appoints 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 Marketplace on March 15, 2012. A few months later the Board hired a CEO.
Marketplace 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 Marketplace 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
Contracting with Plans: In February 2013, HBE released guidance that detailed requirements for Qualified Health Plan (QHP) participation in Healthplanfinder.4 The Marketplace allows all QHPs meeting the minimum standards to participate on Healthplanfinder 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 Marketplace, it must also offer plans in the Silver and Gold levels for that same market. Catastrophic plans may only be sold on Healthplanfinder. 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 Marketplace. Federal requirements specify that 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 Office of the Insurance Commissioner (OIC) requires issuers to offer contracts to all Indian Health centers in their service area, and issuers must notify HBE of all such contracts. There are five geographic rating areas in the state.5
In September 2013, the OIC and the Board certified eight health insurance carriers to offer 38 QHPs for individuals through Washington Healthplanfinder. Eight multi-state plans will also be available. One carrier will offer five plans in the SHOP Marketplace, and SHOP plans will only be available in two counties.6 No platinum level plans are offered in either market. The Board will certify QHPs annually and issuers will offer QHPs for a term of one year.4 Information on plan rates for 2014 is available on the Marketplace website. 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.
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.7 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.
Dental and Vision Benefits: In March 2013, HBE issued final guidance for participation of stand-alone pediatric dental plans in Healthplanfinder. The Board performed final certification of Qualified Dental Plans (QDPs) in September.8 Four dental issuers each offer one stand-alone pediatric dental plan through Healthplanfinder. All plans have low actuarial value (70%).
Risk adjustment, Reinsurance, and Risk corridors (RRR): In a presentation to the Board in September 2012, the Office of the Insurance Commissioner’s Workgroup on RRR expressed a preference for state operated risk adjustment programs.9 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 June 2013, the Marketplace awarded $6 million in grant funding to ten entities to serve as Lead Organizations for the state’s In-person Assistance program. Lead Organizations are responsible for building, training, and managing a network of partners in their region to conduct in-person educational activities and enrollment assistance. Lead Organizations are partnering with almost 100 community organizations across the state and, as of early October, had trained 800 individual in-person assisters (IPAs) to perform outreach and facilitate enrollment through Healthplanfinder. The Marketplace also awarded $420,000 in grant funding to five tribal organizations to support outreach and enrollment activities for members of tribal communities.10 The Washington Healthplanfinder website features a tool that allows consumers to search for in-person assistance according to zip code and service language.
Licensed producers that complete a four to six hour training course and register with the Marketplace are authorized to sell coverage to individuals and small businesses through Healthplanfinder. Producers must be appointed by carriers to sell QHPs and will continue to receive compensation from carriers.11 Training sessions began in mid-August and will be offered through November.12 As of early October, there were over 2,000 trained producers selling plans through the Marketplace statewide. Consumers may search for a broker by zip code and service language on the Marketplace website.
In September 2013, HBE launched the Customer Support Program, which includes a toll-free call line and email inquiry system. The center is open from 7:30am through 8:00pm and will be staffed by 80 full-time trained Customer Support Center representatives. A translation service is available to provide interpretation for approximately 175 languages and all representatives are trained on how to route calls to other agencies.10
HBE’s consumer education campaign includes advertising, grassroots activities, social media, business outreach, and partnerships with media outlets and community organizations. In August 2013, HBE began an online advertising campaign to build Healthplanfinder brand awareness and in September launched a comprehensive advertising campaign that emphasizes how consumers may use the online portal to compare plans and enroll into coverage. Healthplanfinder advertisements appear on television, radio, print, billboards, buses, and in other public areas.13 HBE also produced an eight-part “Countdown to Coverage” webinar series to educate consumers on the Affordable Care Act, how Healthplanfinder works, and the coverage options that will be available in 2014. In April 2013, HBE launched the Washington Healthplanfinder website, including a cost-estimate calculator.
The Marketplace has established key partnerships with entities such as business associations, libraries, hospitals, clinics, community-based alliances, and faith-based organizations, to help spread awareness of the Healthplanfinder and facilitate enrollment statewide. The Marketplace has a series of outreach and enrollment events planned throughout the open enrollment period, including a mobile enrollment tour featuring a customized Washington Healthplanfinder bus. The bus will make stops at nine mobile enrollment event locations throughout the state, and IPAs will use laptops to enroll consumers on-site.14 The Marketplace is also partnering with a nonprofit to develop a smartphone application targeted towards young adults.
Small Business Health Options Program (SHOP) Marketplace: The Washington SHOP Marketplace has experienced significant challenges in recruiting insurers to participate. While seven carriers initially submitted letters of intent to participate in the SHOP, all but one have since withdrawn due to concerns about operational readiness and risk. Despite the limited carrier participation, in May 2013, the Board voted to launch the SHOP on October 1, 2013.15 For 2014, the one participating issuer will offer five QHPS in two counties.
Employers may offer a single health plan or a choice of health plans at a single metal level to employees, and employer premium contribution must be at least 50% for employees. HBE requires 100% employee participation for employer groups with three or fewer employees and employee participation of 75% for employer groups with more than three employees. HBE will collect and aggregate employer premium payments.15
Financing: In July 2013, the Legislature passed SHB 1947 to ensure self-sustainability for the Marketplace beyond 2014. The bill funds the Marketplace using two mechanisms. First, HMOs, health care service contractors, and self-funded employers must pay a 2% tax on premiums collected during the preceding calendar year. Taxes on premiums collected through QHPs offered on the Marketplace and on premiums collected through Medicaid plans for the expansion population will be allocated for Marketplace operations rather than deposited into the general fund. If premium taxes for the current year are insufficient to fund Marketplace operations for the upcoming year, assessments on carriers offering QHPs through Healthplanfinder may be used to generate the necessary funds. Assessments will be collected by the Marketplace on a quarterly basis. The legislation also orders the state auditor to conduct an evaluation of Marketplace costs in 2016 and to make a recommendation to the Board and the Legislature about how best to proceed with financing the Marketplace.16
Basic Health Program (BHP) Option: Washington has considered establishing an optional coverage 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 the Marketplace. The state released a proposal in June 2012 to operationalize a BHP, but awaits final approval from the federal government.17 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.18
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 Marketplace, 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.19 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.
The Washington Health Care Authority has received two federal grants: an Exchange Planning grant of almost $1 million and a Level One Establishment grant of approximately $23 million to be used for operational planning and to develop an information technology system for critical Marketplace functions related to eligibility, enrollment and information exchange. In May 2012, the state was awarded a $127.8 million Level Two Establishment grant to fund Marketplace development through December 2014.20
On December 7, 2012, Washington received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a State-based Marketplace.21 The Washington Healthplanfinder portal became operational on October 1 and began enrolling qualified individuals, families, and small businesses into coverage.
SB 5445, Washington’s 2011 Health Benefit Exchange act.
HB 2319. An Act furthering state implementation of the health benefit exchange. 2012 Regular Session.
Washington Health Benefit Exchange. Guidance for Participation in the Washington Health Benefit Exchange. February 1, 2013.
Washington Healthplanfinder Individual Market 2014 Qualified Health Plan and Qualified Dental Plan Certification Requests. August 21, 2013.
“Washington Health Benefit Exchange Certifies New Health Plan Options Available This Fall.” September 4, 2013.
Consumer Rating System. Health Benefit Exchange Board Meeting. September 19, 2012.
Washington Health Benefit Exchange. Final Guidance for Participation of Dental Plans. March 7, 2013.
Office of the Insurance Commissioner. Reinsurance and Risk Adjustment Workgroup. Exchange Board Presentation. September 19, 2012.
"Washington Healthplanfinder Opens Customer Support Program for New Health Plan Options." September 3, 2013.
Washington Healthplanfinder Broker Fact Sheet.
Washington Health Benefit Exchange. Producer Training and Registration.
“Washington Healthplanfinder Mobile Enrollment Tour Kicks Off in Spokane.” October 16, 2013.
State of Washington 63rd Legislature. Substitute House Bill 1947.
Washington State Proposal for a Federal Basic Health Option. June 18, 2012. Washington State Health Care Authority.
Essential Health Benefits Benchmark Plan Selection- Revised. February 13, 2012. Milliman.
Washington Health Insurance Marketplace Grants Awards List.
Letter from HHS to Governor Gregoire. December 7, 2012.