Oregon Health Exchange Profile
Establishing the Exchange
On June 17, 2011, Governor John Kitzhaber (D) signed SB 99 into law establishing the Oregon Health Insurance Exchange Corporation. That same month, the Governor signed SB 91, which specified requirements of health insurance carriers offering coverage in the state. On March 6, 2012, the legislature passed HB 4164 to approve the final version of the Exchange’s business plan. On October 1, 2012, the Exchange announced that its new name would be Cover Oregon.
Structure: The legislation defines Oregon’s Exchange as a quasi-governmental organization, specifically a “public corporation performing governmental functions and exercising governmental powers.”
Governance: Cover Oregon is governed by a nine-member board, including two ex officio members (or their designees): the Director of the Oregon Health Authority and the Director of the Department of Consumer and Business Services. The Governor appoints seven members who are subject to confirmation by the Senate, with expertise or experience in individual insurance purchasing, business, finance, sales, health benefits administration, individual and small group health insurance, or the use of a health insurance exchange. Also, at least two appointed members must be individual or small business consumers of the Exchange. No more than two appointed members can be employed by, consultant to, or members of a board of directors of the following organizations: an insurer or third-party administrator; an insurance producer; a health care provider, facility, or clinic; or a trade association for these parties. Board members must declare any conflicts of interest and abstain from voting on related issues.
The Oregon Senate confirmed the Governor’s nominees to the Health Insurance Exchange Board on September 23, 2011. They are:
- Liz Baxter (Chair), We Can Do Better
- Teri Andrews (Vice-Chair), CG Industries
- Ken Allen, Oregon American Federation of State and County Municipal Employees
- Dr. George Brown, Legacy Health Systems
- Alea Christofferson, ATL Communications
- Jose Gonzales, Tu Casa Real Estate Corporation
- Gretchen Peterson, Hanna Anderson
The Board appointed an Executive Director on October 6, 2011.
As mandated by the Exchange’s authorizing legislation, the Board created a standing Consumer Advisory Committee to facilitate collection of stakeholder input, in addition to the public forum section on the website where policy questions are posted for public feedback. The Committee meets regularly and includes representatives of individual and small businesses, advocacy organizations, and medical and social service providers. Cover Oregon also maintains a standing Tribal Technical Workgroup and multiple ad hoc stakeholder groups : an Actuarial Workgroup, a Small Business Health Options Program (SHOP) Workgroup, a Carrier Technology Workgroup, an Agent Advisory Committee (will be developed after the initial open enrollment period), a Qualified Health Plan Certification Workgroup, and a Stakeholder Engagement Workgroup.
In addition, a four-member bipartisan and bicameral Legislative Advisory and Oversight Committee for the Oregon Health Insurance Exchange Corporation will oversee the implementation of the Exchange.
Contracting with Plans: Cover Oregon is authorized to act as an active purchaser when contracting with plans, specifically to “limit the number of qualified health plans (QHP) that may be offered through the exchange as long as the same limit applies to all insurers.” While Cover Oregon will not negotiate rates, it will set requirements for QHPs that are stronger than the outside market in several areas. These standards will be the same for all carriers, and carriers’ plans must meet these elevated standards to participate. Carriers may choose to participate in either or both the Individual Exchange and the SHOP, and are not required to participate in the same markets inside and outside the Exchange. Carriers participating in Cover Oregon are required to offer a standard bronze, silver-, and gold-level plan in each service area of each Exchange market – Individual and Small Employer – in which they participate. Carriers offering plans at any metal level must also offer a child-only plan at that level. In addition to the standard plans, carriers have the option to offer the following plans: two non-standard plans; two additional plans that demonstrate innovation in the use of networks, wellness programs or other options not related to premiums or benefits; three platinum plans; and/or one catastrophic plan. However, each carrier may only offer up to three plans in each metal tier, including the standard plans at the bronze, silver, and gold levels. Catastrophic plans may only be sold in the Exchange’s Individual Market to specific populations stipulated in the ACA: individuals under age 30, individuals for whom coverage is unaffordable, and individuals with a hardship.
The Department of Consumer and Business Services created an Advisory Committee to develop standards for bronze- and silver-level plans to help the state monitor and compare plans. In addition, information on carrier quality ratings will be available to consumers on Cover Oregon’s website. The website will display quality information about the participating carriers, including an aggregated experience score based on CAHPS data (Consumer Assessment of Healthcare Providers and Systems) that plans already collect and two encounter-based utilization scores. Cover Oregon anticipates that displayed quality information will change in later years to include measures of patient experience or the impact on disparities in access to care.
In October 2012, Cover Oregon released a Request for Applications to health insurance carriers interested in offering benefit plans through the individual and/or small group exchange. The state later adopted regulations related to certification of QHPs. In May 2013, Cover Oregon announced that twelve health insurance carriers have filed plans to sell on the Marketplace. All twelve have indicated that they will participate in the individual market, and eight will offer plans in the small group market. These carriers submitted QHPs and proposed rates for 2014 to the Insurance Division, which held two weeks of public hearings on the proposed rates. The Division plans to review and approve rates by early July 2013. Cover Oregon must then review the plans for Marketplace-specific requirements and certify the plans as QHPs. Cover Oregon has also released draft medical and dental contracts for carriers. Carrier certification occurs once every two years, and carriers that did not apply initially must wait until 2015 to apply (for the 2016 plan year). Changes to existing QHPs can be made annually, and the plan and rates must be approved by the Insurance Division and certified by the Exchange. Carriers may add plans mid-year, but cannot exceed three plans in each metal tier in a service area.
In June 2013, Cover Oregon released a proposed rule that establishes eligibility standards and the application process for enrollment in a QHP, and for insurance affordability programs available through the Exchange.
Dental and Vision Benefits: QHPs with embedded dental benefits, QHPs without dental benefits, and stand-alone dental plans may be sold on the Exchange. Medical carriers offering plans through Cover Oregon may decide whether to include pediatric dental benefits in a medical offering, and plans that include pediatric dental will be displayed alongside plans that do not. The inclusion or exclusion of pediatric dental benefits will be indicated in the plan details, in the same way as other non-mandatory benefits. Cover Oregon will offer stand-alone dental plans as a separate offer after a medical selection is made. All standalone dental plans must cover the pediatric dental essential health benefit at the high (85%) or low (70%) actuarial value.
Within the individual exchange, all consumers will be given the option to shop for a dental plan, but will not be required to purchase. Within SHOP, an employee will be given the option to shop for a dental plan only if the employer has agreed to sponsor a dental option. The effective date for the dental plan must align with medical coverage and carriers are limited to offering three standalone dental plans in each of the individual and small group markets. There is a separate out of pocket maximum for standalone dental issuers, and the “reasonable out of pocket limit” for Pediatric Dental EHB through Cover Oregon will be $1,000 per member.
Risk Adjustment, Reinsurance, and Risk Corridors: Oregon is considering administering its own risk adjustment and reinsurance programs. Cover Oregon and the Oregon Insurance Division are investigating risk adjustment methodologies, a data model, and potential risk adjustment and reinsurance entities. There is legislation currently in the state senate that would establish an Oregon Reinsurance Program to be operated by the Oregon Medical Insurance Pool Board.
Consumer Assistance and Outreach: Oregon identified a subcontractor to create a brand identity for the exchange and develop a multi-phased communications plan based on market research and the results of focus groups. Cover Oregon’s logo and website were unveiled in October 2012, along with an online calculator for individuals to find out how much financial assistance they might be eligible for when purchasing coverage in 2014. The website offers instant translation into more than 65 languages available on every page. In March 2013, Cover Oregon identified a contractor to implement the marketing and communications plan. The contract will run through December 2014, and may be extended for a maximum of five years. Cover Oregon will use a “phased” launch program, with an Awareness and Education phase beginning in July, and an Enrollment phase continuing through enrollment.
In April 2013, Cover Oregon finalized an intergovernmental agreement with the Oregon Health Authority (OHA) to expand OHA’s existing outreach and application assistance program, which utilizes a network of providers who offer enrollment assistance in public programs. The state will use community partners, which are local organizations that are cultural experts on their community. Staff at these organizations will be known as “application assisters,” a term which encompasses Navigators, In-Person Assisters, and application counselors. Application assisters will conduct eligibility and enrollment for public and private health coverage. Application assisters may help consumers with enrolling in a QHP; however, if consumers need information on QHPs beyond what is available through the website, assisters must refer the consumers to an agent. Agents and brokers will not participate as Navigators, but will be involved in a separate Agent Management program, which utilizes a network of licensed health insurance producers to improve outreach to all geographic areas of the state and to hard-to-reach populations. Insurance producers will be trained annually, be affiliated with the Cover Oregon as certified agents and, when appropriate, coordinate and collaborate with the Navigators. Cover Oregon will collect and pass through any carriers’ commissions or bonus payments to the agents.
OHA released a Request for Proposals (RFP) for community partners on April 11, 2013, and plans to announce grantees in July 2013. Training and certification is required for all application assisters, including paid staff and volunteers, and must be renewed annually. In-person and web-based training will be provided free of charge. Application assisters must pass a background check and will receive an identification number.
Community partners will be eligible to receive performance-based grants, though funding will not be available to support all community partners. Funding opportunities will be made available through OHA and posted on the state’s procurement website, the Oregon Procurement Information Network (ORPIN). Proposals are currently being reviewed for the first funding opportunity, and additional opportunities will be posted in early summer 2013. Additionally, the U.S. Department of Health and Human Services (HHS) announced in May 2013 that 29 federally qualified health centers in Oregon would be eligible for an additional $2.8 million in outreach and enrollment grants. HHS estimates awarding grants in early July 2013. Community partners not receiving a grant will be permitted to provide application assistance as long as they sign an agreement with OHA.
Cover Oregon will also operate a Customer Service Center (call center) to offer assistance to individuals wishing to speak with representatives over the phone. In April 2013, Cover Oregon released an RFP for a customer service contractor(s). The Service Center has 50 full-time employees, with up to 100 supplemental staff in the future, and is now live and receiving phone calls.
Small Business Health Options Program (SHOP) Exchange: Oregon has decided to restrict the SHOP exchange to businesses with 50 or fewer employees in 2014 and 2015, and to 100 of fewer employees beginning in 2016.
Information Technology (IT): The Oregon Health Authority, the state’s Medicaid agency, is managing development of Cover Oregon’s IT infrastructure and web portal, with oversight from an Executive Steering Committee consisting of the directors of Cover Oregon and the Department of Human Services, as well as the Insurance Division Administrator. Oregon has decided to develop a single eligibility and enrollment marketplace for the Exchange, Medicaid, and the Children’s Health Insurance Program (CHIP). In 2011, the state selected an enterprise software platform, which leverages integrated commercial off-the-shelf products. The platform will be used to implement functions such as eligibility determination and financial management into the web portal.
In mid-2012, Oregon identified a subcontractor to assist with development of the web portal, based on design specifications formulated by the Enroll UX 2014 project, a public-private partnership creating design standards for exchanges that all states can use. Another subcontractor was identified to develop external interfaces between the exchange and the state’s Department of Human Services systems, federal data systems, insurance carriers, and SERFF (System for Electronic Rates and Form Filings). A subcontractor was also identified to develop a user interface and Cover Oregon has since established a testing protocol focused on consumer usability and user acceptance. Testing began in late 2012 and will continue through August 2013.
Exchange IT and Medicaid staff meets regularly to discuss coordination of eligibility functions for enrollees, as well as referrals and verification functions. Cover Oregon retained project management consulting services to lay out requirements of the individual and SHOP exchange, a customer service interface, financial systems, and internal IT components. The state has also begun examining business requirements for Medicaid. To assist in financing the IT upgrades of the state’s Medicaid eligibility systems, Oregon applied for and received CMS approval of an Advanced Planning Document for the enhanced federal match.
Financing: Cover Oregon conducted a significant amount of budgeting and forecasting work in the first quarter of 2013 to set an administrative fee on Qualified Health Plans (QHPs) for 2014. Cover Oregon underwent a public rule-making process to establish the fee, and also provided for public input at both Finance and Audit Committee meetings and Board meetings. At its March 2013 meeting, the Board of Directors adopted an administrative fee on health insurers offering QHPs through the Exchange of 2.68% of premium, or $9.38 per member per month (PMPM), for 2014. The fee, along with a $15 million charge on public programs, will generate $32 million in reserves in 2014 (half of Cover Oregon’s 2015 budget of $64 million). Cover Oregon also adopted a temporary rule to establish a monthly administrative fee of $0.93 PMPM on insurers offering standalone dental plans through the Exchange in 2014.
Essential Health Benefits (EHB): The Affordable Care Act requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through an exchange, cover certain defined health benefits. Governor Kitzhaber created an EHB workgroup to recommend a benchmark plan for the individual and small group market. The workgroup, jointly chartered by the Oregon Health Policy Board and the Oregon Health Insurance Exchange presented the final recommendation of Small Group PacificSource Preferred CoDeduct plan to the Exchange Board and the Oregon Health Policy Board in mid-2012. In addition, the federal BlueVision “High Plan” package was defined as the pediatric vision benefit and the state’s CHIP plan as the pediatric dental benefit.
Evaluation Plan: Cover Oregon has developed a draft evaluation plan to measure how well Cover Oregon is achieving its goals and identify operational adjustments that will help to achieve its goals more effectively. Cover Oregon has identified 12 key goals that fall into three categories: (1) Engaging partners and raising consumer awareness, (2) A seamless eligibility and enrollment process and excellent customer service, and (3) Improving accessibility and affordability of coverage and care and the health of Oregonians. For each of these three categories, Cover Oregon’s Evaluation Team will collect and analyze data in program design, implementation, and outcomes. Data will be collected through an Evaluation Database that will store enrollment data from Cover Oregon’s IT system and data from consumer surveys, and join these data for analysis. The Evaluation Team will also conduct focus groups with individual market consumers, employers, Service Center staff, agents, and community partners. Evaluation findings will be disseminated within Cover Oregon and to the public through annual reports, briefs, online data exploration tools, and ad hoc reports. Cover Oregon is seeking input on the draft evaluation plan and establishing an Evaluation Technical Advisory Workgroup (ETAW) to collect stakeholder feedback and advice about evaluation content and methods.
Oregon has received multiple federal grants: the Exchange Planning grant of $1 million, the Early Innovator grant of $48 million to build a modular and reusable IT system, a Level One Establishment grant of $9 million to support the final design and implementation of the Exchange’s business and operations plans through August 2012, a second Level One Establishment grant of $6.7 million to continue to support the planning process through May 2013, and a Level Two Establishment grant of $226.4 million to cover costs associated with testing and implementation of the IT user interface, staffing the call center, and developing multi-media marketing materials. Cover Oregon estimates annual start-up costs between 2011 and 2013 to total approximately $27 million, excluding the development of the IT infrastructure and website which will be funded with the Early Innovator Grant.
In addition, Oregon, along with nine other states, is receiving technical assistance from the Robert Wood Johnson Foundation through the State Health Reform Assistance Network; this assistance includes help with setting up health insurance exchanges, expanding Medicaid to newly eligible populations, streamlining eligibility and enrollment systems, instituting insurance market reforms and using data to drive decisions.
On December 7, 2012, Oregon received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based exchange. Final approval is contingent upon the state demonstrating its ability to perform all required Exchange activities on time and complying with future guidance and regulations.
Additional information about Cover Oregon can be found at: http://www.coveroregon.com, or on Cover Oregon’s Facebook page: https://www.facebook.com/coveroregon or Twitter feed: https://twitter.com/CoverOregon.