2006 SCI National Meeting Presentation Slides - State Coverage ...

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2006 SCI National Meeting Presentation Slides - State Coverage ...

Pooling and Purchasing

Robert Wood Johnson Foundation

State Coverage Initiatives Program

Deborah Chollet

February 23, 2006

Overview

• Defining the pool

• Competing with the market

• Managing risk

• Using insurers

• Relationship to other programs

What Defines the Pool

Definition Matters

• Small groups

• Sole proprietors, self-employed

• Individuals

• Wage level of the firm

• Wage of the worker

• Size and composition of the pool

• Eligibility determination and administrative ease

State agency

– Contracting health plans

• Family income

Relationship to the Market

• Buffered from the market

– Waiting period for coverage

– Substantial subsidy to the pool

• Competes with the market

– No waiting period

– Low subsidy to the pool

The Market Matters:

Risk Selection

• What risk does the market exclude, and how

– Rating practices – community rating, age rating,

firm size, other rating factors

– Benefit design – maternity, Rx, mental health,

high-deductible products

• How is the pool protected

– Market regulation

– Use of state high risk pool


How Does the Pool Manage Risk

How Does the Pool Use Insurers

• Primary care capitation

• Disease management

• Mandatory participation of some, all carriers

• Competitive bidding

• Self-insured

How Does the Pool Relate to Other Programs

• Medicaid/SCHIP

– Can Medicaid/SCHIP eligibles enroll

– Can they qualify for Federal match

State high risk pool

State employee health plan

• Other state programs

Check List

• How is the pool defined

• Does the pool compete with the market

• How is the pool protected from unfavorable risk

selection

• How does the pool manage risk

• How does the pool use insurers

• How does the pool relate to other programs

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