State Marketplace Profiles: West Virginia

Final update made on October 24, 2013 (no further updates will be made)

Establishing the Marketplace

On February 15, 2013, Governor Earl Ray Tomblin (D) submitted a blueprint to Secretary Sebelius for West Virginia to establish a Partnership Marketplace 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 marketplace. ² However, concerns over the sustainability of a state-run marketplace led the Governor to pursue a Partnership Marketplace instead.

Prior to the decision to pursue a Partnership Marketplace, the Health Policy Division within the Office of the Insurance Commissioner (OIC) led the marketplace planning initiative. In January 2012, the OIC released a business plan which documented an approach to implementing the Marketplace.³ In addition, the OIC held a series of public engagement meetings throughout the state and met regularly with stakeholder groups to focus on marketplace 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 Marketplace. Two plans applied and were chosen as QHPs in West Virginia: Highmark Blue Cross Blue Shield and Carelink/Coventry Health Care.⁴ However, Carelink/Coventry Health Care withdrew from the Marketplace in September 2013, leaving Highmark Blue Cross Blue Shield as the only insurer. Highmark offers eleven plans in the individual Marketplace and four plans in the SHOP. Rates were released through Healthcare.gov.⁵

Rates vary based on tobacco use, family composition, age, and geography. West Virginia has established eleven geographic rating areas. Issuers must submit rate information to the Marketplace on an annual basis, and the OIC will review rates for compliance with rating standards.⁶ 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 Marketplace, 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 2013.⁷ 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 Marketplace policy initiatives. Governor Tomblin noted in his letter of intent to establish a Partnership Marketplace that West Virginia does not intend to operate a reinsurance program in 2014.⁸

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.⁹ Navigator entity applications were due on June 7, 2013 and grantees were notified by the federal government on August 15.¹⁰ CMS awarded two organizations approximately $600,000 for the Navigator program in West Virginia.¹¹ However, in September 2013, one of the organizations, West Virginia Parent Training and Information Inc., declined the $365,000 federal grant to be a navigator organization after receiving an inquiry from the State Attorney General.¹² WVPTI did not explicitly cite the inquiry, which directed the nonprofit to answer 26 questions about their personnel and hiring practices, as the reason the group declined the grant.

The state selected an In-Person Technical Assistance contractor in July 2013 to help select IPA entities that will operate around the state. ¹³ IPAs will focus on assisting vulnerable and underserved populations in the individual private and public markets. The state requires that IPAs meet the same training, privacy and security, and conflict of interest standards as outlined in federal guidance on Navigators. The state estimated a need of 270 IPAs during open enrollment, and approximately 30 IPAs during non-peak periods. IPAs are available in 46 of 55 counties and an available list of IPAs in West Virginia is available through the state’s health insurance Marketplace website.¹⁴ 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.¹⁵

Organizations can apply to be Certified Application Counselors through CMS and assist consumers in the application and enrollment process. Additionally, 27 Health Centers have been awarded outreach and enrollment assistance grants from HRSA to assist eligible consumers to enroll in coverage.¹⁶ More than 800 local assisters have been trained as of September 30, 2013.¹⁷

Coordination with Medicaid: West Virginia is expanding its Medicaid program to individuals with incomes below 138% of the federal poverty level. Eligibility will be determined through the federal healthcare.gov and those who qualify for Medicaid will be directed to the state Medicaid website.¹⁸ West Virginia has sent letters to more than 170,000 people who were signed up for the Supplemental Nutrition Assistance Program (SNAP) and qualified for Medicaid.¹⁹ For those who respond to these letters, they will be automatically enrolled in Medicaid in November.

Essential Health Benefits: 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. 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.

Marketplace 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. ²⁰ 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 Marketplace.²¹

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 Partnership Marketplace.²² On October 1, West Virginia launched a consumer website that provides information on Navigators and In-person Assisters by county and links to healthcare.gov where consumers can apply for and enroll in coverage.

Additional information about the West Virginia Marketplace can be found at: http://bewv.wvinsurance.gov/ and www.healthcare.gov