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WSHIP

ADMINISTRATOR’S REPORT November 2016

An Executive Summary of Administrator’s Monthly Operations Report and Pool Activities YEAR-TO-DATE (YTD) ENROLLMENT SUMMARY

Total Enrollment as of 11/30/16: 1,450 (increased 1% from prior month)

Number/percentage sponsored by Third Party: 879 / 61%

Non-Medicare Enrolled: 422 / 29% (decreased < 1% from prior month) Sponsored by 3rd Party: 296 / 70% of non-Medicare enrollment

Number sponsored by EHIP: 253 Number sponsored by other: 43

Medicare Enrolled: 1,028 / 71% (decreased < 2% from prior month) Sponsored by 3rd Party: 583 / 57% of Medicare enrollment Enrollment YTD: 197 Terminations YTD: 383

Plan Selection: Non-Medicare: PPO – 371 / 26%, Standard – 38 / 3%, HSA – 13 / < 1%

Medicare: Basic – 818 / 56%, Basic Plus – 210 / 14%

Age & Gender: Average age: 56 Gender: Female– 41%, Male– 59%

MONTHLY ENROLLMENT ACTIVITY (Non-Medicare enrollment is closed) Number of applications received: 22 (Medicare) Number of applications approved: 13 (Medicare)

Eligibility Category: Rejected for medical reasons: 11 Offered reduced Medicare supplement: 0 Medicare supplement not offered in county: 0 Medicare supplement not available because under age 65: 2

Access to Medicare Advantage Plans: Do not have reasonable choice: 2 Provider not included in available plans: 0 ESRD Diagnosis – unable to obtain a Medicare Advantage Plan: 11

Percent of applications submitted by Agents: 23% Percent of applications submitted by Third Party: 36%

Terminations in the reporting month: 43 Medicare Terminations: 39 Non-Medicare Terminations: 4

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MONTHLY CLAIMS EXPENSE

Medical Claims Paid: $2,937,664 Pharmacy Claims Paid: $1,379,366 Estimated Claims Incurred But Not Paid: $4,627,000

OTHER MONTHLY ACTIVITY

Claims Activity: Number of claims received: 6,209 Claims inventory: Received but not adjudicated – 929 / Pended - 24

Customer Service Telephone Calls and Website Visitors: Average calls per day: 34 Average website visitors per day: 22

Monthly Care Management Activity: Utilization Management Reviews Inpatient: 5 Outpatient: 0 Case Management Number of open cases: 26 Number of closed cases: 0 New cases: 1

Appeals: Number of appeals received related to eligibility: 7 First Level (Administrator) 6; Second Level (Grievance Committee) 1 Number of appeals received related to other: 2 First Level (Administrator) 2; Second Level (Grievance Committee) 0

Number of appeals adjudicated in favor of applicant/enrollee: 4 Number of appeals adjudicated and denied: 5

Number of retro-termination requests: 0 Number of reinstatement requests: 7

OIC Complaints: Number of complaints received: 0

Administrator’s Levels of Service: ☐ Administrator met all levels of service. ☒ Administrator did not meet the following levels of service:

Standard 16 - 100% responsible for posting web site updates within 48 hours of receipt.

Monthly Operations Report

Monthly Operations Report

November 2016

November ApplicationsMedicare Applications Received 22Medicare Applications Pended 18Medicare Applications Approved 13

Pending DeniedNo Signature 0% 0%No Proof of Residency 5% 0%No Rejection Letter 0% 0%No C of C 0% 0%No Summary of Benefits 0% 0%No Voided Check 0% 0%No Bank Authorization (for EFT's only) 5% 0%No Payment Included 84% 0%Withdrawn 0% 0%Other 5% 100%Total 100% 100%Clean App Turn TimeID Card Issuance Turn TimeClosed for Lack of information (total)Percentage of clean apps received 18%

Reasons

Washington State Health Insurance Pool (WSHIP)

2.0 days2.18 days

0%

November Statistics

Enrollment ActivityNovember 2016

2

0

100

200

300

400

500

600

700

800

900

Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16

Washington State Health Insurance Pool (WSHIP) 13 Month Enrollment Count

Standard $500 Standard $1000 Standard $1500 PPO $500 PPO $1000

PPO $2500 PPO $5000 HSA PPO $3000 Basic Plus Basic

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HSA Qual PPO Plan

Basic Plus Plan Basic Plan

Age $500 $1,000 $1,500 Age $500 $1,000 $2,500 $5,000 Age $3,000 Age0-18 4 0 0 0-18 11 2 0 1 0-18 0 0-18 0 019-29 4 0 2 19-29 9 4 5 0 19-29 0 19-29 0 930-34 1 0 1 30-34 32 5 1 0 30-34 0 30-34 1 1635-39 3 0 0 35-39 53 1 2 1 35-39 0 35-39 0 2440-44 4 0 0 40-44 58 2 4 2 40-44 2 40-44 3 5145-49 1 1 1 45-49 55 0 9 2 45-49 2 45-49 4 6850-54 6 2 2 50-54 35 3 5 1 50-54 0 50-54 18 10355-59 0 0 0 55-59 19 1 9 3 55-59 4 55-59 31 14960-64 1 1 1 60-64 13 4 10 6 60-64 5 60-64 41 17265-69 0 0 1 65-69 1 0 0 0 65-69 0 65-69 36 10370-74 2 0 0 70-74 1 0 0 0 70-74 0 70-74 38 6775-79 0 0 0 75-79 0 0 1 0 75-79 0 75-79 20 2980-84 0 0 0 80-84 0 0 0 0 80-84 0 80-84 15 2185+ 0 0 0 85+ 0 0 0 0 85+ 0 85+ 3 6Total 26 4 8 Total 287 22 46 16 Total 13 Total 210 818

1,450

Washington State Health Insurance Pool (WSHIP)Plan & Age Distribution Summary

November 2016

Total Medicare Enrollment = 1028

TOTAL ENROLLMENT:

Total STD Plan Enrollment = 38

Standard Plan PPO Plan

Total Non-Medicare Enrollment = 422Total PPO Plan Enrollment = 384

0

200

400

600

800

1,000

26 4 8

287

22 46 16 13

210

818

$500 Std. Plan $1000 Std. Plan $1500 Std. Plan $500 PPO Plan $1000 PPO Plan

$2500 PPO Plan $5000 PPO Plan $3000 HSA Plan Basic Plus Plan Basic Plan

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HSA Qual PPO Plan

Age $500 $1,000 $1,500 Age $500 $1,000 $2,500 $5,000 Age $3,0000-18 0 0 0 0-18 0 0 0 0 0-18 019-29 0 0 0 19-29 4 0 0 0 19-29 030-34 0 0 0 30-34 30 0 0 0 30-34 035-39 0 0 0 35-39 49 0 0 0 35-39 040-44 0 0 0 40-44 56 0 0 0 40-44 045-49 0 0 0 45-49 53 0 0 0 45-49 050-54 0 0 0 50-54 33 0 0 0 50-54 055-59 0 0 0 55-59 18 0 0 0 55-59 060-64 0 0 0 60-64 8 0 0 0 60-64 065-69 0 0 0 65-69 1 0 0 0 65-69 070-74 0 0 0 70-74 1 0 0 0 70-74 075-79 0 0 0 75-79 0 0 0 0 75-79 080-84 0 0 0 80-84 0 0 0 0 80-84 085+ 0 0 0 85+ 0 0 0 0 85+ 0Total 0 0 0 Total 253 0 0 0 Total 0

TOTAL ENROLLMENT: 253

Total Non-Medicare Enrollment = 253

Washington State Health Insurance Pool (WSHIP)EHIP Plan & Age Distribution Summary

November 2016

Standard Plan PPO Plan

Total STD Plan Enrollment = 0 Total PPO Plan Enrollment = 253

050

100150200250300

0 0 0

253

0 0 0 0

$500 Std. Plan $1000 Std. Plan $1500 Std. Plan $500 PPO Plan

$1000 PPO Plan $2500 PPO Plan $5000 PPO Plan $3000 HSA Plan

5

22%

33%

44%

0%

0%

0%

0%

0%

18%

36%

36%

0%

0%

0% 9%

0%

6%

0%

9%

3% 6%

0%

0%

17%

42%

42%

0%

0%

0%

0%

0% 13

% 25

%

13%

25%

0%

25%

0%

0%

0

5

10

15

20

25

Non-Payment Death Other Coverage Moved Out ofState

Insured Request Medicare Financial Hardship Loss of 3rd PartyPayor

Num

ber o

f Enr

olle

es

Terminations by Reason July 2016 - November 2016

July August September October November

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.

Yearly totals may not total 100% due to rounding.

79%

6

0

2,000

4,000

6,000

8,000

10,000

12,000

Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16

7,063 6,480 6,581

8,058

6,968 6,851 7,236

6,229

7,062

6,056

6,766

6,209

Washington State Health Insurance Pool (WSHIP) Claims Received

December 2015 - November 2016 Average Claims Received = 6,819

7

0

200

400

600

800

1,000

1,200

1,400

Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16

574

1,624 1,497

1,359

1,017

779

557

363

620

871

1,269

929

26 23 49 42

123 46 64 68 53 26 38 24

Washington State Health Insurance Pool (WSHIP) Claims Inventory

December 2015 - November 2016

Pre-Registered Pended

Average Pre-Registered Claims = 955 Average Pended Claims = 49

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Month / Year Case Provider Total Billed Total Paid Date of ServiceDate

Received Date Paid Primary Diagnosis

December 2015 3 Providence Centralia Hospital $230,210.61 $100,651.81 11/10/15 - 12/1/15 12/14/15 12/23/15 D59.5 - Paroxysmal nocturnal hemoglobinuria

4 Harborview Medical Center $919,934.47 $473,024.13 10/1/15 - 12/2/15 12/11/15 12/24/15 A41.02 - Sepsis due to Methicillin resistant Staph

January 2016 None

February 2016 5Providence Sacred Heart

Medical Center $158,733.80 $111,113.66 1/11/16 - 1/14/16 1/21/16 2/23/16 N18.6 - End stage renal disease

March 2016 None

April 2016 3 Providence Centralia Hospital $278,788.06 $120,701.62 3/8/16 - 4/5/16 4/13/16 4/21/16 D59.5 - Paroxysmal Nocturnal Hemoglobinuria

4Regional Hospital for

Respiratory and Complete $225,518.59 $171,957.95 12/2/15-12/31/15 3/14/16 4/12/16 J96-01 - Acute Respiratory Failure with Hypoxia

4Regional Hospital for

Respiratory and Complete $141,343.06 $112,684.31 1/1/16-1/31/16 3/23/16 4/5/16 J96-01 - Acute Respiratory Failure with Hypoxia

4Regional Hospital for

Respiratory and Complete $144,020.30 $109,815.50 2/1/16-2/27/16 3/16/16 4/12/16 J96-01 - Acute Respiratory Failure with Hypoxia

May 2015 None

June 2016 None

July 2016 4 Harborview Medical Center $277,767.69 $174,363.59 4/12/16 - 6/3/16 7/1/16 7/22/16S14.154D - Other incomplete lesion at C4 level of cervical spinal cord, subsequent encounter

August 2016 None

September 2016 None

October 2016 3 Providence Centralia Hospital $284,936.55 $124,778.89 09/06/16-10/4/16 10/12/16 10/18/16 D59.5 - Paroxysmal Nocturnal Hemoglobinuria

November 2016 None

12 Month Average Amount Billed: $221,771.09

12 Month Average Amount Paid: $124,924.29

Washington State Health Insurance Pool (WSHIP)High Dollar Paid Claims Report

December 2015 - November 2016

9

0

20

40

60

80

Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16

52 49

53 47

39

42 39

33 37 35

13

34

22

27 26

22

16 16 15

13 14 16

25 22

Washington State Health Insurance Pool (WSHIP) Average Calls & Web Site Visitors Per Day

December 2015 - November 2016

Telephone Contacts Web Site Visitors

Average Telephone Calls Per Day = 39 Average Web Site Visitors Per Day = 20

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ENROLLEES Inquiry Type Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16Monthly Average

AppealsExplanation of Appeals Process / Status of Appeal 0 1 0 5 0 0 3 0 1 0 0 1 1

Benefit Information Plan Inquiry 31 31 16 21 23 16 18 9 16 9 2 21 18Benefit Information Health Care Reform 0 0 0 0 0 0 0 0 0 0 0 0 0

BillingFinance Issues / Premium Due / Rates / Billing Status 13 7 5 5 8 8 13 7 9 9 4 20 9

Claims Claim Status 47 28 18 47 31 42 41 33 45 43 16 41 36Claims EOB Questions 4 6 13 3 1 2 1 7 3 8 3 5 5Claims Response to letter 10 5 2 2 3 0 2 2 2 2 1 5 3Claims Other 47 34 40 61 29 34 31 18 34 23 11 51 34Enrollment Application Status 3 0 3 0 3 1 1 0 0 0 1 4 1Enrollment Member Eligibility / ID Card 62 30 35 45 16 31 24 10 23 23 6 51 30RX Inquiry Benefit Question / Filing Claims 0 0 3 3 0 1 0 1 0 0 0 0 1

TOTAL 217 142 135 192 114 135 134 87 133 117 44 199 137

PROVIDERS Inquiry Type Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16Monthly Average

AppealsExplanation of Appeals Process / Status of Appeal 2 1 2 0 1 3 0 1 0 1 0 0 1

Benefit Information Plan Inquiry 157 150 161 164 154 143 140 115 139 115 45 71 130Benefit Information Healthcare Reform 0 0 0 0 0 0 0 0 0 0 0 0 0

BillingFinance Issues / Premium Due / Rates / Billing Status 4 9 6 4 9 7 5 8 2 2 3 4 5

Claims Claim Status 84 47 74 73 62 72 46 54 65 54 19 59 59Claims EOB Questions 3 0 1 3 0 1 1 3 0 3 0 1 1Claims Response to letter 1 0 3 1 0 1 2 2 2 4 1 1 2Claims Other 63 65 50 70 47 39 57 35 48 32 13 39 47Enrollment Application Status 1 2 2 1 2 1 0 2 0 3 4 7 2Enrollment Member Eligibility / ID Card 256 262 278 314 247 248 289 206 275 272 72 105 235RX Inquiry Benefit Question / Filing Claims 0 0 0 1 0 0 0 0 0 0 0 0 0

TOTAL 571 536 577 631 522 515 540 426 531 486 157 287 482

Washington State Health Insurance Pool (WSHIP)Customer Service Call Types

December 2015 - November 2016

11

AGENTS Inquiry Type Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16Monthly Average

AppealsExplanation of Appeals Process / Status of Appeal 0 1 0 0 0 0 0 0 0 0 0 0 0

Benefit Information Plan Inquiry 0 0 1 0 0 0 0 0 0 0 0 0 0Benefit Information Healthcare Reform 0 0 0 0 0 0 0 0 0 0 0 0 0

BillingFinance Issues / Premium Due / Rates / Billing Status 1 1 0 0 0 0 3 0 2 0 0 2 1

Claims Claim Status 0 0 0 0 1 0 0 0 1 0 0 0 0Claims EOB Questions 0 0 1 2 1 1 0 0 0 0 0 0 0Claims Response to letter 0 0 0 0 0 0 0 0 0 1 0 0 0Claims Other 3 1 3 1 2 3 17 2 2 2 1 4 3Enrollment Application Status 3 2 6 5 5 3 5 1 4 2 1 4 3Enrollment Member Eligibility / ID Card 11 8 2 2 2 4 12 4 3 6 1 2 5RX Inquiry Benefit Question / Filing Claims 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0TOTAL 18 13 13 10 11 11 37 7 12 11 3 12 13

CARRIERS Inquiry Type Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16Monthly Average

AppealsExplanation of Appeals Process / Status of Appeal 0 0 0 0 0 0 0 0 0 0 0 0 0

Benefit Information Plan Inquiry 0 0 0 0 0 0 0 0 1 0 0 0 0Benefit Information Healthcare Reform 0 0 0 0 0 0 0 0 0 0 0 0 0

BillingFinance Issues / Premium Due / Rates / Billing Status 0 0 1 0 3 1 1 0 0 0 0 1 1

Claims Claim Status 0 0 0 0 0 0 0 0 0 0 0 0 0Claims EOB Questions 0 2 0 1 0 1 3 2 1 0 0 0 1Claims Response to letter 0 0 0 0 0 0 0 0 0 0 0 0 0Claims Other 4 4 1 0 1 2 1 1 0 2 1 1 2Enrollment Application Status 0 0 0 0 0 0 1 0 1 2 1 2 1Enrollment Member Eligibility / ID Card 6 1 1 2 1 5 3 0 2 1 1 3 2RX Inquiry Benefit Question / Filing Claims 0 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 10 7 3 3 5 9 9 3 5 5 3 7 6

Washington State Health Insurance Pool (WSHIP)Customer Service Call Types

December 2015 - November 2016

12

TOTAL Inquiry Type Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16Monthly Average

AppealsExplanation of Appeals Process / Status of Appeal 2 3 2 5 1 3 3 1 1 1 0 1 2

Benefit Information Plan Inquiry 188 181 178 185 177 159 158 124 156 124 47 92 147Benefit Information Healthcare Reform 0 0 0 0 0 0 0 0 0 0 0 0 0

BillingFinance Issues / Premium Due / Rates / Billing Status 18 17 12 9 20 16 22 15 13 11 7 27 16

Claims Claim Status 131 75 92 120 94 114 87 87 111 97 35 100 95Claims EOB Questions 7 8 15 9 2 5 5 12 4 11 3 6 7Claims Response to letter 11 5 5 3 3 1 4 4 4 7 2 6 5Claims Other 117 104 94 132 79 78 106 56 84 59 26 95 86Enrollment Application Status 7 4 11 6 10 5 7 3 5 7 7 17 7Enrollment Member Eligibility / ID Card 335 301 316 363 266 288 328 220 303 302 80 161 272RX Inquiry Benefit Question / Filing Claims 0 0 3 4 0 1 0 1 0 0 0 0 1

TOTAL 816 698 728 836 652 670 720 523 681 619 207 505 638

Note - Healthcare Reform was added as an Inquiry Type in March '10

Washington State Health Insurance Pool (WSHIP)Customer Service Call Types

December 2015 - November 2016

13

0.00

1.00

2.00

3.00

4.00

Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16

Washington State Health Insurance Pool (WSHIP) OIC Inquiries Received

December 2015 - November 2016

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Contractual Levels of Service

Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16Enrollment Standards1. 14 day Clean Application Process 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%2. 30 day ID Card Issuance 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%3. Accuracy 99% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%Billing Standards4. 14 day Paid-to Status Update 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%5. Accuracy 99% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%Claims Standards6. 100% Notification 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%7. 30 day Clean Claim Process 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%8. Clerical Accuracy 98% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9%9. Financial Accuracy 99% 99.9% 99.9% 100% 99.9% 99.9% 99.9% 99.9% 99.9% 99.9% 100% 99.9% 99.8%10. Overall Processing Accuracy 97% 99.3% 99.7% 99.8% 99.6% 99.4% 98.9% 99.7% 99.3% 99.5% 99.4% 98.9% 99.2%Customer Service Standards11. 60 Sec. Speed of Answer 60 sec 42 78 39 42 26 27 26 33 44 41 18 2112. 5% Abandonment Rate 5% 1.8% 5.8% 2.1% 2.4% 1.9% 1.2% 1.0% 1.2% 2.3% 1.7% 1.1% 0.8%13. Accuracy 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%14. 48 hour Web Mail Response 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%15. Premium Refunds 99% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%16. Updates posted w/in 48 hours 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 67%Measurement of StandardsStandard 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 - 100% response rate for 48-hour turn-around of online CSR email during the reporting month.Standard 15 - 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 16 - 100% responsible for posting web site updates within 48 hours of receipt.

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