1 PCIP-WA ADMINISTRATOR’S REPORT July 2012 An Executive Summary of Administrator’s Monthly Operations Report and HHS Report INCEPTION-TO-DATE ENROLLMENT SUMMARY Total Enrolled/Approved as of 7/31/12*: 911 *Coverage may not be effective until a subsequent month Number/percentage sponsored by Third Party: 494 (35%) Percentage of sponsored enrollees from EHIP: 96% Percentage of sponsored enrollees from other: 4% Enrolled/Approved ITD: 1396 Newborns Enrolled ITD: 0 Terminations ITD: 549 Plan Selection: $2,500 deductible plan– 55% $500 deductible plan– 45% Top five pre-existing conditions: 1. AIDS 2. Cancer 3. Pregnancy 4. Diabetes 5. Coronary Artery Disease Age & Demographics: Average age: 43 Gender: Female– 43%, Male– 57 % Top five counties of residence: King, Pierce, Snohomish, Clark, Spokane Citizenship: U.S. Citizens – 88%, Lawfully Present in the U.S. – 12% Employment: Employed – 43%, Unemployed – 57% MONTHLY ENROLLMENT ACTIVITY Number of applications received: 64 Number of applications approved: 56 Number of applications pended: 26 Number of applications denied: 3 Primary denial reason: no pre-existing condition Number of newborns enrolled: 0 Percent of applications submitted by agents: 20% Percent of applications qualifying by evidence of pre-existing condition: 79% Percent of applications qualifying by submittal of denial letter or rider: 21% Terminations in the reporting month: 53 Notable comparisons/observations: We had an increase in voluntary terminations this month.
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PCIP-WA
ADMINISTRATOR’S REPORT July 2012
An Executive Summary of Administrator’s Monthly Operations Report and HHS Report INCEPTION-TO-DATE ENROLLMENT SUMMARY
Total Enrolled/Approved as of 7/31/12*: 911 *Coverage may not be effective until a subsequent month
Number/percentage sponsored by Third Party: 494 (35%) Percentage of sponsored enrollees from EHIP: 96% Percentage of sponsored enrollees from other: 4%
Number of applications received: 64 Number of applications approved: 56 Number of applications pended: 26 Number of applications denied: 3 Primary denial reason: no pre-existing condition Number of newborns enrolled: 0
Percent of applications submitted by agents: 20% Percent of applications qualifying by evidence of pre-existing condition: 79% Percent of applications qualifying by submittal of denial letter or rider: 21%
Terminations in the reporting month: 53
Notable comparisons/observations: We had an increase in voluntary terminations this month.
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MONTHLY CLAIMS EXPENSE
Medical Claims Paid: $2,413,869 Pharmacy Claims Paid: $919,420 Estimated Claims Incurred But Not Paid: $9,939,000
OTHER MONTHLY ACTIVITY
Claims Activity: Number of claims received: 2,548 Claims inventory: Received but not adjudicated – 272 / Pended – 185 Number of EHIP claims received: 428 Total dollars paid on EHIP claims: $103,021.61
Customer Service Telephone Calls and Website Visitors: Average calls per day: 52 Average website visitors per day: 13
Notable observations/comparisons: The majority of calls are regarding verification of benefits. We continue to receive a significant number of calls regarding Health Care Reform as well.
Appeals: Number of appeals received related to eligibility: 7 Number of appeals received related to other: 7 Number of appeals adjudicated in favor of applicant/enrollee: 10 Number of appeals adjudicated and denied: 4
Administrator’s Levels of Service: X Administrator met all levels of service. Administrator did not meet the following levels of service:
Monthly Operations Report
Monthly Operations Report
July 2012
July Statistics Pending DeniedNo Signature 0% 0%No Proof of Residency 31% 33%No Rejection Letter 0% 0%No Voided Check -for EFT only 12% 0%No Bank Authorization -EFT only 0% 0%"Other" Condition Marked, but no Diagnosis Code 0% 0%Physician's Statement 23% 0%Incomplete Application 12% 33%No Premium Payment 12% 0%No Proof of Citizenship 8% 0%No Pre-existing Condition 0% 33%Creditable Coverage within the last 6 months 4% 0%Withdrawn 0% 0%Total 100% 100%Total Applications DeniedClean App Turn Time
*Approved applications include applications that were pended ID Card Issuance Turn Timeprior to the reporting month for effective dates prior to the Percentage Closed for Lack of information reporting month. Percentage of clean apps received
Pre-existing Condition Insurance Plan - Washington State (PCIP-WA)Enrollment Activity
Pre-existing Condition Insurance Plan - Washington State (PCIP-WA)EHIP Plan & Age Distribution Summary
This report does not reflect people who enrolled with future effective dates.
PPO Plan
July 2012
3
46%
2%
22%
22%
7%
43%
0%
17%
30%
9%
47%
0%
21%
16%
16%
46%
0% 0%
38%
15%
46%
4%
0%
42%
8%
0
2
4
6
8
10
12
14
16
18
20
Insured Request Deceased Non-Payment Other Insurance Moved out of State
Num
ber o
f Enr
olle
es
Terminations by Reason(March 2012 - July 2012)
March April May June July
NOTE: This chart depicts the reasons why coverage was terminated for enrollees. Non-payment does not reflect the actual reason for termination. At the time of termination for non-payment, the administrator queried the member for the actual reason. "Insured Request" indicates those who did not state a reason for terminating.
Monthly totals may not total 100% due to rounding.
Pre-existing Condition Insurance Plan - Washington State (PCIP-WA)Claims Inventory
August 2011 - July 2012
Pre-Registered Pended
Average Pre-Registered Claims =230Average Pended Claims =124
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Month / Year Case Provider Total Billed Total Paid Date of Service Date Date Paid Primary Diagnosisy
August 2011 NoneSeptember 2011 1 Sacred Heart Medical Center $162,839.73 $67,991.05 07/20/11-07/21/11 08/02/11 09/02/11 428.0 Congestive heart failure
2 Tacoma General AllenMore $62,825.20 $54,430.32 08/05/11-08/10/11 08/18/11 09/07/11 v58.11 Encounter for antineoplastic chemotherapyOctober 2011 1 Harrison Memorial Hospital $81,645.65 $76,293.29 08/29/11-09/01/11 09/13/11 10/28/11 733.42 Aseptic necrosis of head and neck of femur
2 Johns Hopkins Hospital $355,673.81 $345,513.62 04/03/11-05/19/11 06/14/11 10/11/11 996.71 Other complications due to heart valve prosthesis3 St. Joseph's Medical Center $83,815.28 $61,136.57 08/09/11-08/09/11 09/07/11 10/27/11 225.2 Benign neoplasm of cerebral meninges4 University of Washington $70,694.51 $60,688.98 08/30/11-09/08/11 09/15/11 10/26/11 151.0 Malignant neoplasm of cardia5 Harrison Memorial Hospital $59,075.88 $54,594.53 08/05/11-08/06/11 08/24/11 10/28/11 233.0 Carcinoma in situ of breast6 Tacoma General AllenMore $57,468.50 $54,430.32 09/13/11-09/17/11 09/27/11 10/26/11 v58.11 Encounter for antineoplastic chemotherapy7 Tacoma General AllenMore $65,640.25 $54,430.32 08/23/11-08/27/11 09/07/11 10/19/11 v58.11 Encounter for antineoplastic chemotherapy
November 2011 1 Queen of Valley Hospital $66,559.58 $60,701.50 07/09/11-07/14/11 09/02/11 11/10/11 572.2 Hepatic encephalopathy
December 2011 1 Mayo Hospital Arizona $93,767.45 $85,647.74 03/29/11-04/07/11 8/25/2011 8/31/2011 150.4 Malignant neoplasm of middle third of esophagus
January 2012 1 Deaconess Medical Center $98,067.03 $59,095.05 11/14/11-11/24/11 11/30/2011 1/17/2012 158.0 malignant neoplasm of retroperitoneum
February 2012 1 Swedish Medical Center - Cherry Hill $339,439.59 $196,478.18 9/20/11-10/10/11 1/10/2012 2/2/2012 141.0 Malignant neoplasm of base of tongue
2 University of Washington $133,583.37 $116,217.53 12/13/11-12/29/11 1/12/2012 2/8/2012 787.01 Nausea with vomiting
3 Swedish Medical Center - Cherry Hill $166,909.15 $72,391.23 6/16/11-7/08/11 2/13/2012 2/24/2012 787.01 Nausea with vomiting
March 2012 1 Good Samaritan Hospital $146,946.85 $96,915.04 1/26/12-2/27/2012 2/27/2012 3/20/2012 153.6 Malignant neoplasm of ascending colon
2 St. Joseph's Medical Center $77,578.30 $51,977.46 11/10/11-11/20/11 3/6/2012 3/30/2012 V30.00 Single liveborn,born in hospital,delivered without mention of cesarean section
3 Harborview Medical Center $76,781.21 $50,423.33 1/27/12-2/03/12 2/13/2012 3/30/2012801.20 Closed fracture of base of skull with subarachnoid,subdural, and extradural
hemorrhage, unspecified state of consciousness
April 2012 1 Sacred Heart Medical Center $343,056.13 $163,165.21 2/10/12-3/15/12 3/27/2012 4/10/2012 324.1 Intracranial and intraspinal abscess of unspecified site
2 Harrison Medical Center $109,915.04 $102,535.69 01/13/12-01/15/12 3/5/2012 4/2/2012 414.01 Coronary atherosclerosis of native coronary artery
May 2012 1 Good Samaritan Hospital $823,869.15 $342,692.39 10/4/11-12/8/11 5/2/2012 5/8/2012 560.81 Intestinal or peritoneal adheasions with obstruction
2 Tacoma General AllenMore $256,533.90 $170,704.36 8/24/11-8/26/11 4/16/2012 5/18/2012 715.17 Osteoarthrosis, localized, primary; bilateral primary osteoarthrosis of the knee
3 Tacoma General AllenMore $249,425.55 $156,143.47 9/19/11-10/17/11 4/16/2012 5/18/2012 998.59 Postoperative Infection; other postoperative infection
4 Deaconess Medical Center $220,147.27 $138,913.78 2/12/12-2/25/12 4/30/2012 5/14/2012197.6 Secondary malignant neoplasm of respiratory and digestive systems;
Standard 1 - If the date received compared to the date approved for all clean applications approved during the reporting month is less than 14-days.Standard 2 - If the date received compared to the date mailed for all applications approved during the reporting month is less than 30-days from receipt of eligible application to issuance of identification card.Standard 3 - 99% or greater accuracy rate for enrollment coding of premium, plan and age rate categories for all approved applications during the reporting month.Standard 4 - 100% scoring of (25) member audit of 14-calendar days or less from premium receipt to update of eligibility file paid-to-status.Standard 5 - 99% scoring of (25) member audit of accuracy for posting of correct payment, implementation of rate changes and premium account reconciliations during the reporting month.Standard 6 -100% notification for all claims not paid within 10-business days during the reporting month.Standard 7 - 100% of clean claims processed within 30-calendar days during the reporting month.Standard 8 - 98% or greater accuracy rate for clerical coding of claims based on a 5% claim audit during reporting month.Standard 9 - 99% or greater accuracy for benefit and payment of claims based on a 5% claim audit during reporting month. Standard 10 - 97% or greater overall claims processing accuracy for benefit and payment of claims based on a 5% claim audit during reporting month.Standard 11 - 60 second or less average speed of answer for all telephone inquiries received during the reporting month.Standard 12 - 5% or less call abandonment rate.Standard 13 - 95% or greater accuracy based on a 2% enrollee audit for accuracy of customer service response to inquiry during the reporting month.Standard 14 - 99% or greater of premium refunds issued (or checks returned) within 15 days of all ineligible and denied applications based on a 2% enrollee audit during reporting month.Standard 15 - 100% responsible for posting web site updates within 48 hours of receipt.
