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West Virginia Health Exchange Profile

West Virginia

Establishing the Exchange

On February 15, 2013, Governor Earl Ray Tomblin (D) submitted a blueprint to Secretary Sebelius for West Virginia to establish a state-partnership exchange with plan management responsibilities. In the previous year, Governor Tomblin had signed SB 408 into law to establish the West Virginia Health Benefits Exchange and the state had begun exploring implementation options for a state-based exchange. However, concerns over the sustainability of a state-run exchange led the Governor to pursue a partnership exchange instead.

Prior to the decision to pursue a partnership exchange, the Health Policy Division, within the Office of the Insurance Commissioner (OIC), led the exchange planning initiative. In January 2012, the OIC released a business plan which documented an approach to implementing the Exchange. In addition, the OIC held a series of public engagement meetings throughout the state and met regularly with stakeholder groups to focus on exchange implementation issues related to carriers, consumers, producers, and providers.

Contracting with Plans: In April, 2013 the West Virginia Offices of the Insurance Commissioner (OIC) released a Qualified Health Plan Submission Guide to provide guidance to health insurance issuers regarding the certification standards for individual and SHOP Qualified Health Plans (QHPs) offered through the Exchange. OIC expects issuers to submit QHPs April 1 – May 31 of 2013, and will review submissions and recommend QHPs to the Department of Health and Human Services (HHS) April 1 – July 31 of 2013. OIC expects issuers to enter into certification agreements with HHS in August 2013.

Rates may vary based on tobacco use, family composition, age, and geography. West Virginia will use eleven geographic rating areas. Issuers must submit rate information to the Exchange on an annual basis, and the OIC will review rates for compliance with rating standards.

Acting as a clearinghouse, OIC will accept plans that meet federal and state certification criteria. The State has partnered with the West Virginia School of Osteopathic Medicine to develop a strategy to maximize and report on provider quality in the Exchange, such as through measurement and reporting, purchasing , and engaging consumers through better information.

Risk Adjustment, Reinsurance, and Risk Corridors: In 2011, the West Virginia legislature passed HB 2745 to develop an all-payer claims database and the state expects to begin collecting data in 2013. This database will provide the baseline information to create a risk adjustment program, as well as to provide outcome quality data and enable analyses of exchange policy initiatives. Governor Tomblin noted in his letter of intent to establish a state-partnership exchange that West Virginia does not intend to operate a reinsurance program in 2014.

Consumer Assistance and Outreach: The federal government will administer the state’s Navigator program, while the West Virginia OIC will oversee an In-Person-Assister (IPA) program. CMS has allocated $600,000 for the Navigator program in West Virginia.7 Navigator entity applications were due on June 7, 2013 and grantees will be notified by the federal government on August 15.

The state selected an In-Person Technical Assistance contractor in July 2013 to help select IPA entities that will operate around the state. IPAs will focus on assisting vulnerable and underserved populations in the individual private and public markets. They will likely receive training in the small group market as well, to assist individuals that do not have an agent-consumer relationship. The state plans to have IPAs meet the same training, privacy and security, and conflict of interest standards as outlined in federal guidance on Navigators. The state currently estimates a need of 270 IPAs during open enrollment, and approximately 30 IPAs during non-peak periods. IPA entities will be selected in June and trained and certified in August of 2013. Outreach efforts will be conducted in August-September 2013. West Virginia will rely on the federal government for mass marketing and branding of the marketplace. The IPA vendor may perform some marketing at the local level.

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. Since West Virginia did not put forward a recommendation, the state’s benchmark EHB plan will default to the largest small-group plan in the state, Highmark (Blue Cross Blue Shield of West Virginia)- Super Blue Plus 2000 PPO.

Exchange Funding

The West Virginia Office of the Insurance Commissioner received a federal Exchange Planning grant of $1 million in September 2010 and a federal Level One Establishment grant of $9.7 million in August 2011. The Establishment grant will be used to study consumer quality and effectiveness, complete economic modeling, and investigate risk adjustment strategies and policy integration with state agencies.In July 2013, West Virginia received a second Level One Establishment grant for $10.2 million to support the IPA program and plan management activities. The state requested and received a No Cost Extension for the Establishment grant, in part due to the delay of the release of an RFP for an actuarial assessment and economic model of the Exchange.

Next Steps

On March 5, 2013, West Virginia received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-partnership 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 the West Virginia Exchange can be found at:

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