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PCIP-WA

ADMINISTRATOR’S REPORT October 2012

An Executive Summary of Administrator’s Monthly Operations Report and HHS Report INCEPTION-TO-DATE ENROLLMENT SUMMARY

Total Enrolled/Approved as of 10/31/12*: 992 *Coverage may not be effective until a subsequent month

Number/percentage sponsored by Third Party: 551 (34%) Percentage of sponsored enrollees from EHIP: 92% Percentage of sponsored enrollees from other: 8%

Enrolled/Approved ITD: 1598 Newborns Enrolled ITD: 0 Terminations ITD: 688

Plan Selection: $2,500 deductible plan– 55% $500 deductible plan– 45%

Top five pre-existing conditions: 1. AIDS 2. Pregnancy 3. Cancer 4. Diabetes 5. Coronary Artery Disease

Age & Demographics: Average age: 42 Gender: Female– 44%, Male– 56 %

Top five counties of residence: King, Pierce, Snohomish, Clark, Spokane

Citizenship: U.S. Citizens – 88%, Lawfully Present in the U.S. – 12%

Employment: Employed – 44%, Unemployed – 56% MONTHLY ENROLLMENT ACTIVITY

Number of applications received: 66 Number of applications approved: 60 Number of applications pended: 19 Number of applications denied: 3 Primary denial reason: incomplete applications Number of newborns enrolled: 0

Percent of applications submitted by agents: 20% Percent of applications submitted by EHIP/Third Party Payers: 23% Percent of applications qualifying by evidence of pre-existing condition: 62% Percent of applications qualifying by submittal of denial letter or rider: 38%

Terminations in the reporting month: 65

Notable comparisons/observations: There was a large increase in voluntary terminations

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MONTHLY CLAIMS EXPENSE

Medical Claims Paid: $2,676,137 Pharmacy Claims Paid: $887,573 Estimated Claims Incurred But Not Paid: $8,943,000

Notable observations/comparisons: While Medical claims Paid have remained fairly consistent, Pharmacy claims were about $20,000 higher in Oct. than Sept.

OTHER MONTHLY ACTIVITY

Claims Activity: Number of claims received: 3,341 Claims inventory: Received but not adjudicated – 483 / Pended – 146 Number of EHIP claims received: 660 Total dollars paid on EHIP claims: $141,422.86

Customer Service Telephone Calls and Website Visitors: Average calls per day: 52 Average website visitors per day: 14

Notable observations/comparisons: The majority of calls are regarding verification of benefits. We continue to receive a significant number (15%) of calls regarding Health Care Reform as well.

Appeals: Number of appeals received related to eligibility: 1 Number of appeals received related to other: 5 Number of appeals adjudicated in favor of applicant/enrollee: 5 Number of appeals adjudicated and denied: 1

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

Monthly Operations Report

Monthly Operations Report

October 2012

October Statistics Pending DeniedNo Signature 0% 0%No Proof of Residency 26% 0%No Rejection Letter 0% 0%No Voided Check -for EFT only 5% 0%No Bank Authorization -EFT only 0% 0%"Other" Condition Marked, but no Diagnosis Code 0% 0%Physician's Statement 16% 0%Incomplete Application 5% 33%No Premium Payment 11% 0%No Proof of Citizenship 16% 33%No Pre-existing Condition 0% 0%Creditable Coverage within the last 6 months 21% 33%Withdrawn 0% 0%Total 100% 100%Total Applications DeniedClean App Turn Time

*Approved applications include applications that were pended ID Card Issuance Turn Timeprior to the reporting month for effective dates prior to the Percentage Closed for Lack of information reporting month. Percentage of clean apps received

Pre-existing Condition Insurance Plan - Washington State (PCIP-WA)Enrollment Activity

October 2012

5%44%

3 days3 days

3

Reasons

20 25 30 35 40

PPO $500

PPO $2,500

PPO $500 PPO $2,500

Received 29 37

Applications Received in the Reporting Month

0 2 4 6 8 10 12 14

PPO $500

PPO $2,500

PPO $500 PPO $2,500

Pended 7 12

Applications Pended in the Reporting Month

0 10 20 30 40

PPO $500

PPO $2,500

PPO $500 PPO $2,500

Approved 25 34

Applications Approved in the Reporting Month*

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Age $500 $2,5000-18 1 319-29 97 6030-34 62 4835-39 70 4340-44 65 3945-49 69 6850-54 33 7255-59 19 7760-64 14 9865-69 1 270-74 0 375-79 0 180-84 0 285+ 0 0Total 431 516

947Total Enrollment =

Pre-existing Condition Insurance Plan - Washington State (PCIP-WA)Plan & Age Distribution Summary

October 2012This report does not reflect people who enrolled with future effective dates.

PPO Plan

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Age $500 $2,5000-18 0 019-29 73 030-34 47 035-39 55 040-44 55 045-49 65 050-54 29 055-59 16 060-64 10 065-69 0 070-74 0 075-79 0 080-84 0 085+ 0 0Total 350 0

350Total Enrollment =

Pre-existing Condition Insurance Plan - Washington State (PCIP-WA)EHIP Plan & Age Distribution Summary

This report does not reflect people who enrolled with future effective dates.

PPO Plan

October 2012

3

46%

0% 0%

38%

15%

46%

4%

0%

42%

8%

28%

11%

28%

11%

22%

50%

0%

7%

36%

7%

20%

0%

13%

53%

13%

0

2

4

6

8

10

12

Insured Request Deceased Non-Payment Other Insurance Moved out of State

Num

ber o

f Enr

olle

es

Terminations by Reason(June 2012 - October 2012)

June July August September October

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.

Monthly totals may not total 100% due to rounding.

4

0

500

1,000

1,500

2,000

2,500

3,000

3,500

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

1,9592,118

1,9131,837

2,512

2,919

2,6602,498 2,548

2,772

2,348

3,341

Pre-existing Condition Insurance Plan - Washington State (PCIP-WA)Claims Received

November 2011- October 2012Average Claims Received = 2,452

5

0

100

200

300

400

500

600

700

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

158 153

74

180

208

614

278

473

272

375

208

483

7089

5891 98

208

253

177185

103 112146

Pre-existing Condition Insurance Plan - Washington State (PCIP-WA)Claims Inventory

November 2011 - October 2012

Pre-Registered Pended

Average Pre-Registered Claims =290Average Pended Claims =133

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Month / Year Case Provider Total Billed Total Paid Date of Service Date Rcvd Date Paid Primary Diagnosisy

November 2011 1 Queen of Valley Hospital $66,559.58 $60,701.50 07/09/11-07/14/11 09/02/11 11/10/11 572.2 Hepatic encephalopathy

2 Legacy Emmanuel Hospital $74,899.79 $52,389.39 08/02/11-08/03/11 10/22/2011 11/23/2011 441.4 Abdominal aneurysm without rupture

December 2011 1 Mayo Hospital Arizona $93,767.45 $85,647.74 03/29/11-04/07/11 8/25/2011 8/31/2011 150.4 Malignant neoplasm of middle third of esophagus

January 2012 1 Deaconess Medical Center $98,067.03 $59,095.05 11/14/11-11/24/11 11/30/2011 1/17/2012 158.0 malignant neoplasm of retroperitoneum

February 2012 1 Swedish Medical Center - Cherry Hill $339,439.59 $196,478.18 9/20/11-10/10/11 1/10/2012 2/2/2012 141.0 Malignant neoplasm of base of tongue2 University of Washington $133,583.37 $116,217.53 12/13/11-12/29/11 1/12/2012 2/8/2012 787.01 Nausea with vomiting

3 Swedish Medical Center - Cherry Hill $166,909.15 $72,391.23 6/16/11-7/08/11 2/13/2012 2/24/2012 787.01 Nausea with vomiting

March 2012 1 Good Samaritan Hospital $146,946.85 $96,915.04 1/26/12-2/27/2012 2/27/2012 3/20/2012 153.6 Malignant neoplasm of ascending colon

2 St. Joseph's Medical Center $77,578.30 $51,977.46 11/10/11-11/20/11 3/6/2012 3/30/2012V30.00 Single liveborn,born in hospital,delivered without mention of cesarean

section

3 Harborview Medical Center $76,781.21 $50,423.33 1/27/12-2/03/12 2/13/2012 3/30/2012801.20 Closed fracture of base of skull with subarachnoid,subdural, and

extradural hemorrhage, unspecified state of consciousness

April 2012 1 Sacred Heart Medical Center $343,056.13 $163,165.21 2/10/12-3/15/12 3/27/2012 4/10/2012 324.1 Intracranial and intraspinal abscess of unspecified site

2 Harrison Medical Center $109,915.04 $102,535.69 01/13/12-01/15/12 3/5/2012 4/2/2012 414.01 Coronary atherosclerosis of native coronary artery

May 2012 1 Good Samaritan Hospital $823,869.15 $342,692.39 10/4/11-12/8/11 5/2/2012 5/8/2012 560.81 Intestinal or peritoneal adheasions with obstruction

2 Tacoma General AllenMore $256,533.90 $170,704.36 8/24/11-8/26/11 4/16/2012 5/18/2012715.17 Osteoarthrosis, localized, primary; bilateral primary osteoarthrosis of the

knee

3 Tacoma General AllenMore $249,425.55 $156,143.47 9/19/11-10/17/11 4/16/2012 5/18/2012 998.59 Postoperative Infection; other postoperative infection

4 Deaconess Medical Center $220,147.27 $138,913.78 2/12/12-2/25/12 4/30/2012 5/14/2012197.6 Secondary malignant neoplasm of respiratory and digestive systems;

Retroperitoneum and peritoneum

5 Good Samaritan Hospital $333,193.30 $133,321.16 8/18/11-9/3/11 5/2/2012 5/4/2012 625.3 Dysmenorrhea

6 Providence St Peter $194,680.59 $92,326.37 11/28/11-12/6/11 2/22/2012 5/9/2012 721.3 Lumbosacral spondylosis without myelopathy

7 Good Samaritan Hospital $121,338.40 $77,443.95 10/4/11-12/8/11 5/2/2012 5/8/2012 560.81 Intestinal or peritoneal adheasions with obstruction

8 Harborview Medical Center $88,018.10 $62,784.30 4/10/2012 4/19/2012 5/2/2012 198.3 Brain or spinal cord secondary malignant neoplasm

9 Columbia Capital Med $74,503.71 $51,062.24 11/16/11-11/20/11 4/16/2012 5/9/2012 724.02 Lumbar region, without neurogenic claudication

June 2012 1 Peacehealth SW Med Center $127,401.30 $73,204.83 3/30/12-4/12/12 5/14/2012 6/13/2012 038.0 Streptococcal septicemia

2 Sinai Hospital Baltimore $61,411.05 $59,625.83 2/27/12-3/1/12 4/24/2012 6/11/2012 996.47 Other mech complication prosthetic joint implant

3 Northern Idaho Advanced $77,305.03 $54,113.53 3/15/12-4/17/12 5/14/2012 6/5/2012 780.72 Functional quadriplegia

4 University of Washington $65,612.67 $51,666.57 3/15/12-3/21/12 6/4/2012 6/15/2012 170.4 Malignant neoplasm scapula & long bones upper limb

July 2012 1 Oregon Health & Science Univ $145,949.18 $86,649.00 4/1/12-4/25/12 6/5/2012 7/19/2012 205.10 Chron myeloid leukemia w/o achieved remission

2 University of Washington $109,498.67 $83,218.99 6/6/12-6/9/12 6/19/2012 7/23/2012 225.2 Benign neoplasm of cerebral meninges

3 Good Samaritan Hospital $161,484.75 $80,742.37 12/8/11-12/31/11 6/29/2012 7/3/2012 V57.89 Other specified rehabilitation procedure other

4 St Francis Community Hospital $143,013.28 $67,487.17 6/22/12-7/4/12 7/16/2012 7/27/2012 154.1 Malignant neoplasm of rectum

6 St Joseph Medical Center $82,331.57 $58,448.81 5/24/2012 6/11/2012 7/9/2012 350.1 Trigeminal neuralgia

7 Providence St Peter Hospital $105,312.08 $54,130.41 12/29/11-12/31/11 6/21/2012 7/16/2012 414.01 Coronary atherosclerosis of native coronary artery

August 2012 1 U W Medical Center $149,085.56 $119,047.70 5/2/12-5/6/12 5/22/2012 8/1/2012 585.6 End stage renal disease

2 St Joseph Medical Center $252,048.44 $112,386.00 6/26/12-6/30/12 7/12/2012 8/8/2012 424.0 Mitral valve disorders

3 U W Medical Center $88,951.03 $74,402.37 7/5/12-7/12/12 7/30/2012 8/27/2012 746.4 Congenital insufficiency of aortic valve

4 Sacred Heart Medical Center $77,593.04 $66,671.06 7/17/12-7/26/12 8/6/2012 8/27/2012 038.11 Methicillin susceptible staph aureus septicemia

5 SW WA Med Ctr - Patient Accts $105,867.05 $65,574.84 5/28/12-6/25/12 7/12/2012 8/10/2012 V30.00 Single liveborn hospital w/o c-section

September 2012 1 Swedish Cherry Hill $181,341.19 $111,721.52 8/1/12-8/6/12 8/21/2012 9/19/2012 747.81 Congenital anomaly of cerebrovascular system

2 Tacoma General Allenmore $196,161.60 $109,740.89 8/3/12-8/7/12 8/16/2012 9/10/2012 715.35 LOC osteoarthros not spec prim/sec pelv RGN&THI

3 St Joseph Medical Center $190,204.16 $102,993.74 7/31/12-8/7/12 8/20/2012 9/5/2012 552.21 Incisional hernia with obstruction

4 Deaconess Hospital $100,223.68 $72,348.97 8/8/2012 8/15/2012 9/10/2012 191.8 Malignant neoplasm of other parts of brain

5 Providence St Peter Hospital $86,379.34 $53,659.26 6/8/12-6/12/12 9/25/2012 9/27/2012 414.01 Coronary atherosclerosis of native coronary artery

October 2012 1 Swedish Medical Center $249,206.10 $134,076.31 4/27/12-5/28/12 9/25/2012 10/10/2012 V30.01 Single liveborn hospital deliv by c-section

2 Central Washington Hospital $90,873.12 $83,905.64 9/6/2012 10/4/2012 10/25/2012 425.4 Other primary cardiomyopathies

3 Western Regional Med Ctr $95,992.00 $77,993.50 9/10/2012 10/10/2012 10/19/2012 141.0 Malignant neoplasm of base of tongue

4 Peacehealth St Joseph $65,380.90 $63,161.26 8/2/2012 9/12/2012 10/3/2012 V58.0 Radiotherapy

5 Yakima Regional Medical $107,176.59 $61,479.04 8/22/12-8/24/12 9/4/2012 10/3/2012 722.4 Degeneration of cervical intervertebral disc

6 United General Hospital $56,830.00 $50,010.40 9/4/2012 10/10/2012 10/19/2012 V58.0 Radiotherapy

12 Month Average 12 Month Average

Amount Billed: Amount Paid:

Washington State Health Insurance Pool (PCIP-WA)High Dollar Paid Claims ReportNovember 2011 - October 2012

$605,153.90 $363,482.45Includes claims with paid amounts ≥ $100,000 through March 2011 and ≥ $50,000 from April 2011 on.

7

0

10

20

30

40

50

60

70

Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

51

61

65

5355 54

4946

5250

52 52

812 12 12

7 7 7 8

13 12 1214

Pre-existing Condition Insurance Plan - Washington State (PCIP-WA)Average Calls & Web Site Visitors Per Day

November 2011 - October 2012

Telephone Contacts Web Site Visitors

Average Telephone Calls Per Day = 53Average Web Site Visitors Per Day = 10

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Insd / Prov Inquiry Type Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 June-12 Jul-12 Aug-12 Sep-12 Oct-12Monthly 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 42 23 41 74 81 65 70 36 57 43 47 32 51Benefit Information Health Care Reform 37 42 41 17 27 21 27 24 22 43 45 48 33

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

Claims Claim Status 0 1 1 0 0 0 2 1 2 1 0 0 1Claims EOB Questions 0 0 0 0 1 0 0 0 0 0 0 0 0Claims Response to letter 1 1 1 1 2 3 0 0 1 0 0 0 1Claims Other 81 43 82 103 141 81 96 84 102 87 57 99 88Enrollment Application Status 0 4 4 0 0 10 1 0 8 24 15 28 8Enrollment Member Eligibility / ID Card 0 0 0 2 0 0 3 0 1 2 3 2 1RX Inquiry Benefit Question / Filing Claims 0 0 0 0 0 0 0 1 0 0 0 0 0

TOTAL 161 115 171 198 252 183 199 146 193 201 167 211 183

PB & E Inquiry Type Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 June-12 Jul-12 Aug-12 Sep-12 Oct-12Monthly Average

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

Benefit Information Plan Inquiry 196 235 307 331 333 337 311 276 275 254 214 304 281Benefit Information Health Care Reform 36 40 50 58 67 79 61 75 64 116 68 78 66

BillingFinance Issues / Premium Due / Rates / Billing Status 0 1 4 7 9 10 4 4 3 0 6 8 5

Claims Claim Status 20 36 36 57 26 27 23 52 56 81 78 64 46Claims EOB Questions 1 1 5 3 6 9 11 12 5 4 6 4 6Claims Response to letter 7 4 3 5 8 7 2 1 5 2 5 6 5Claims Other 70 74 104 102 75 63 65 78 80 72 57 50 74Enrollment Application Status 4 2 4 4 1 2 1 1 1 6 5 10 3Enrollment Member Eligibility / ID Card 37 48 41 54 22 42 53 60 70 83 54 86 54RX Inquiry Benefit Question / Filing Claims 0 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 371 441 554 621 547 576 531 561 561 618 493 612 541

Pre-existing Condition Insurance Plan - Washington State (PCIP-WA)Call Types November 2011 - October 2012

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Pre-existing Condition Insurance Plan - Washington State (PCIP-WA) Levels of Service

November 2011 - October 2012Contractual

Levels of ServiceNov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

Enrollment 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% 100% 100% 100% 100% 99.9% 99.9% 100% 99.9% 100% 99.9% 98.6% 100%9. Financial Accuracy 99% 99.9% 99.9% 99.9% 99.9% 100% 100% 99.9% 100% 100% 100% 100% 100%10. Overall Processing Accuracy 97% 100% 100% 100% 100% 98.5% 98.7% 100% 99.2% 99.3% 100% 99.3% 99.4%Customer Service Standards11. 60 Sec. Speed of Answer 60 sec 30 30 27 24 25 29 25 39 58 48 49 3912. 5% Abandonment Rate 5% 2% 2% 2% 2% 2% 4% 4% 3% 4% 5% 5% 3%13. Accuracy 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%14. Premium Refunds 99% 100% 100% 100% 100% 100% 100% 100% 100% 100% 82% 100% 100%15. Updates posted w/in 48 hours 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Standard 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 - 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 15 - 100% responsible for posting web site updates within 48 hours of receipt.

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