Ernie Sweat CEBSUtah Health Exchange Advisory Board

Limited to small employers (2-50)

One of two operational exchanges in the country

Market Driven

Up to 114 plans available

Regence Blue Cross Blue Shield

United Healthcare

Select Health

Humana

Regence Blue Cross Blue Shield

United Healthcare

Select Health

Humana

$43/Subscriber$37 to agent$6 to administrators

Added to Raw Rates

Included for all enrollees(even without agent)

Bswift

Health Equity

Prospective Risk Adjustment

Retrospective Risk Adjustment

Employees Complete Universal Applications

Two Carriers in Exchange are Randomly Selected to Underwrite Risk

Rateups are Assigned

If Carriers are Within 30 points, the Average is Assigned

If Outside of 30 Points, a Third Carrier (mediator) is Randomly Selected to Underwrite

Average of two Closest Carriers is Taken to Assign Final Rateup

CAVEAT:Utah State Law Requires Rate Tables Inside

the Exchange to be no Higher than the Underwritten Rate Tables Outside the Exchange

Health Score is Assigned to Each Individual in the Group

Algorithm is used to Average Health Scores for Employees Selecting Each Carrier

Higher Scores Mean a Higher Premium Allotment

All Premium is Pooled and then Allocated to Carriers

New and Terminated Employees are Added to/Subtracted from Algorithm

Average Score is Recalculated Monthly

High Risk Pooling

Claims in Excess of Pooling Level ($75,000) are Identified

Only Claims Between $75,000 and $250,000 are Pooled

75% of Each Qualifying Claim is Calculated

High Risk PoolingExample:

Carrier A: Has a Claim of $100,000 ($25,000 over Pooling Level) $25,000 x 0.75 = $18,750

Carrier B: Has a Claim of $155,000 ($80,000 over Pooling Level) $80,000 x 0.75 = $60,000

Example:Carrier A: $25,000 x 0.75 = $18,750Carrier B: $80,000 x 0.75 = $60,000

Total: $78,750 Tally is Divided by the Membership of

the ExchangeExample: 15,000 Members =

$5.25/Member

Each Carrier Multiplies that Figure by Their Total MembershipExample: Carrier A: 5,000 Members x $5.25 =

$26,250

Amount Determined is Sent to High Risk Pool

High Risk Pool Funds are Distributed to Carriers Who Incurred Large ClaimsCarrier A: $26,250

$18,750

All Dollars from Pool are Distributed to Risk Affected Carriers

Settlement Takes Place 6 Months after Plan Year Zero Sum Game

Access to Multiple Networks

No Minimum Contribution

Both Maternity and Non-Maternity plans may be offered

No restriction on plan options

Exchange 1.0

Bswift

Health Equity

Exchange 2.0

Bswift

Health Equity

eHealthapp

Exchange 1.0Attend Defined Contribution Training SessionMust be Appointed with the majority of the

carriers Exchange 2.0

Attend Updated UHE TrainingAttend Utah Premium Partnership TrainingComplete eHealthapp TrainingMust be appointed with all carriers

Exchange 1.0

Requires employer applicationCumbersome excel spreadsheetBanking data required upfront Employee application via BswiftData unavailable outside Exchange

Exchange 2.0

Broker registers employerNo spreadsheet requiredEmployee application via eHealthappBroker submits group to underwriting

once applications are completeData can be shared with other carriers

as well as Exchange

2.0 AdvantagesBanking data collected AFTER group

selects Exchange as carrierBroker owns the applicationBetter visibility of applicationsAddition of group documents libraryMarketing materials in development

stage

Exchange 1.0

Primary and Secondary Underwriter

Primary Underwriter collects data via Bswift

Secondary Underwriter and Mediator collect data independently

Exchange 2.0

2 primary UnderwritersEach Underwriter receives data

automatically from eHealthappMediator uses same processMuch faster turnaround

Mandated method of employer contribution

Must be determined before employees make elections

Must also choose default plan at this time

Can elect to have excess funds go to HSA account

Health Equity Optum Bank

Employee data from enrollment forms sent to Bswift

Allows employees to have additional time to make selections

Exchange 1.090 daysGenerally earlier than renewal date

Exchange 2.060 daysCan coordinate with renewal dateHolidays may extend this process

Exchange 1.0Handled by Health EquityFunded by broker commission

Exchange 2.0Governed by the Utah Health ExchangeFunded by carriers

Utilizes Calling Tree

Bswift – EnrollmentHealth Equity – BillingeHealthapp – Group EnrollmentUtah Insurance Department – Exchange

OverviewCarriers – Claims and specific questions

Exchange 1.0 Invoice emailed to client on the 5th of prior

month Initial ACH withdrawal takes place on the 8th of

prior monthExchange 2.0

Invoice emailed to client on the 17th of prior month

Initial ACH withdrawal takes place 10 days prior to effective date

Subsequent ACH withdrawals can be moved to late in billing month

Exchange 1.0Received a trend increase

Exchange 2.0Beginning January 1, 2012

PEHP will underwrite Each group rated separately Will utilize any available information

RAB still determining a permanent solution Intending to use All Payer Claim Database

Quality and Cost Data on carriers and providers

Utilize Utah Health Information Network

Mine feedback from consumers

Utilize Federal Funds

Grants

Vouchers

Integrate MedicaidPossible training for agents

Add the individual market

Determine underwriting and risk adjustment process

Decide plan designs▪ Likely that these will match the group market

Define the role and training of navigatorsMust they be licensed?Must they carry E&O insurance?Must they be appointed by the carriers?Will the training regimen be different from

that of an agent?Will there truly be a distinction between

navigator and agent?

Addition of the larger employer sector

Integration of 51-99 market

Is there a place for 100+??

Ernie Sweat801-814-4949Esweat@FBAbenefits.com