Agent Training Packet-03-04 - WSHIP · • Any licensed agent can get paid by WSHIP • Today’s agent training gives you the chance to be on the WSHIP referral list – To be available

WSHIPWashington State Health Insurance Pool

Presenters:Seattle: Sean Corry, CLUSpokane: Jan Dawson, RHU

Sprague Israel Giles, Inc.

Why Are We Here?

• Agent WSHIP Training – Thanks, WAHU• To be on WSHIP’s referral list • Agent Compensation• Not to Mention CE Credits


Why Agent Training?

• The application process is confusing!• 2002 WSHIP survey:

– Only a quarter of the rejected applicants actually enroll in WSHIP

• WHY???• Cost and Confusion are the two primary

reasons given


Why Agent Training? (continued)

WSHIP Wants:• Administrative efficiencies• Knowledgeable agents, and • WSHIP will pay you for your assistance!


What is WSHIP?

• WSHIP is like an insurance company• Established by the State in 1987 • To provide access to coverage for the

rejected sick• WSHIP offers 3 types of medical plans

(Traditional, Medicare, PPO)


What is WSHIP? (continued)

• WSHIP is part of the individual market• Individual policies• Individual premiums

– 110% - 150% higher than “comparable”individual plans in the market (This is law.)

– Not nearly high enough to pay the actual costs– The difference between premiums and total

costs is made up through “ASSESSMENTS”


What Are WSHIP Assessments?

• Because WSHIP premiums can be no higher than 150% of comparable commercial plans…

• And enrollees are the sickest and most costly…• Premiums paid by enrollees cover only a third of

the actual costs of coverage.• The difference is paid by the carriers. They are

ASSESSED their proportionate share of the cost, • Based on their share of the general health

insurance market in Washington State.


WSHIP Assessments (continued)

Who gets assessed? • “Member Plans” selling health insurance (group

individual, or disability). This includes all: • HMOs (Group Health)• Service Contractors (Premera, Regence)• Commercial Insurers (Aetna, Prudential)• Stop-loss Carriers/HCA (Safeco, State plans)

(Special deal – ten cents on the dollar)

• Life and dental companies are excluded


WSHIP Assessments (last slide!)

• WSHIP assessments become part of the premiums paid in the individual and group markets

• Assessments in 2002 were about $27 million• This works out to be about $0.75 per month, for

each person insured in the individual and group markets (roughly 3 million people)

• On a $200 monthly premium, this is a “tax” of about four tenths of one percent.


WSHIP Players

• WSHIP Board of Directors

• Kären Larson, Executive Director

• Benefit Management, Inc. (BMI) – Plan Administration

• First Choice PPO Network


WSHIP History

Ancient History:• 1987 – costs going up, medical underwriting had

become common

• Carriers were excluding people, or body parts

• WSHIP to the rescue! “To ensure the availability of comprehensive health insurance” (RCW 48.41.020)

• Risk Pool Model – NAIC and…. “Communicating for Agriculture”


WSHIP History (slide 2)

The Middle Ages:• 1993 Health Care Reform Legislation

• Coverage available to all without barriers

• New enrollment in WSHIP became dormant until 1999, when, of course, the market shut down

• WSHIP was opened in counties where no commercial policies were available


WSHIP History (slide 3)

The Modern Era:• 2000 legislation opens up the individual market• New Board: 4 Carriers, 6 Governor-appointed,

and the Insurance Commissioner (but no vote!) • Standard Health Questionnaire designed to screen

out the “8% most costly”• Carriers must use only SHQ if they want to screen

applicants


Standard Health Questionnaire

• SHQ is 25 pages, more or less, but it’s not as bad as it looks

• Section A has 25 health conditions, any of which get you rejected immediately

• The next 12 sections are based on body systems or types of disorders, making it fairly easy to complete

• Can take from one minute to a few hours



• Hundreds of health conditions are included• Each has a point score, based on expected

cost of care - (not severity of condition)• Score more than 288 points?• Rejection by carrier nearly certain



• SHQ actuarially certified every 18 months to assure that it screens the 8% most costly.

• April 2002 was first redraft and actuarial recertification– Several items were clarified or expanded to

make it “fairer” to applicants• Next recertification scheduled for July

2003, for use in October


The Application Process

• Apply for private coverage– Carrier application, along with the SHQ, are

submitted (without money)• Carrier has 15 business days after receipt to

send notice of rejection• If carrier rejects, the rejection notice is sent

to applicant along with a separate WSHIP application


Carrier Rejection

The only way to get to WSHIP coverage is if the carrier

first rejects the applicant


The SHQ Is Not Always Used

Carriers are not allowed toscreen applicants

under the following four circumstances:


SHQ Not Always Used

Exception 1:• SHQ is not required if you apply for

individual coverage within 90 days of the completion of the full COBRA period.


SHQ Not Always Used

Exception 2: • If you apply for individual coverage

within 90 days of the end of your COBRA coverage, lost because your former employer has gone out of business.


SHQ Not Always Used

Exception 3:• If you apply for individual coverage

within 90 days after moving to a new area, and you are applying with a new carrier because your former carrier is not available.


SHQ Not Always UsedException 4: • If your doctor has left your provider

network but is in another network, and you apply for individual coverage within 90 days with a new plan that includes your doctor. You must have had service with that doctor within the last 12 months.


WSHIP Application Packet

• Only 44 pages!• Has all the information you need about:

– Eligibility, summary, rates and rate discounts privacy, appeals and grievances, etc.

• Of course, it includes the APPLICATION• The Application Packet was revised in

April, 2003


Six Different WSHIP Policies

Plan 1: Three “Traditional” Plans• Deductibles: $500, $1,000, or $1,500• 80/20 coinsurance• Two-tiered Rx copays, that vary with

deductible: $7/15, $10/20, or $12/25• “Passive PPO” overlay, First Choice

Network


Plan Designs (continued)

Plan 2: For Medicare Eligibles• No deductible• Secondary to Medicare - acts as a

Medicare Supplement• 80/20 coinsurance• Rx Copays $5/$10


Plan Designs (continued)

Plan 3: Network (PPO) Plan• Two deductibles: $500 or $1,000• First Choice Network• Coinsurance:

– 80/20 in network– 60/40 out


WSHIP Premiums

By law, monthly premiums can be:• No higher than 150% of the “comparable”

commercial plans, except;• Network Plan (PPO) can be no higher than

125% of the “comparable” commercial plans, and

• NO premiums can be lower than 110%


WSHIP Premiums

• Age-rated in all plans: 5-year brackets• Rates vary by plan and deductible choices• Gender/smoking status do not apply• Rate examples:

– Basic rates, age 45: $432 - $591– Medicare rates, age 45: $343– Medicare rates, age 70: $499


WSHIP Premium Discounts

Premium Discounts for Low Income:• Two levels, based on family income:

– 251% to 301% for the federal poverty level– Less than 251% of the federal poverty level

• Applies ONLY if applicant is between 50 and 64 years old.

• Available ONLY if WSHIP funds are available



Additional Premium Discount for:• Having been enrolled in a prior plan for at

least 18 months



Another Premium Discount for:• Having been enrolled in WSHIP for more

than 36 months



Combined Premium Discount for:• Coming onto a WSHIP plan with 18 months

of prior continuous coverage AND• Being enrolled in WSHIP for more than 36

months



In No Casecan the WSHIP premium be lower than 110% of the

“Standard Risk Rate”

(i.e., the rate for “comparable” plans)


Agent Compensation

• One time, $50 agent “finder’s fee”• Agent must be named on page 26 in the

WSHIP application• The application form will be changing in

April, but for now the agent section looks like this:


Final Details

• Any licensed agent can get paid by WSHIP• Today’s agent training gives you the chance

to be on the WSHIP referral list– To be available on the www.wship.org Website

and on WSHIP paper• However, you must complete the form in

your packet for this purpose


WSHIP

Questions?Sprague Israel Giles, Inc.

Thank You Very Much☺


Documents

Agent Training Packet-03-04 - WSHIP · • Any licensed agent can get paid by WSHIP • Today’s agent training gives you the chance to be on the WSHIP referral list – To be available