For Insurers

Mapping hierarchy for cross-carrier to qualified health plans

Washington state Qualified Health Plan auto-reenrollment mapping hierarchy for Plan Year 2024.

Hierarchy one: priority enrollment

First, the Health Benefit Exchange will determine an enrollee’s mapped Qualified Health Plan (QHP) based on the following criteria:

  • If there is more than one QHP available at the enrollee’s same metal level and same plan type*, the Exchange will then map based on the lowest  enrollee costs, taking into consideration both annualized premium and annual deductible.

* The Health Benefit Exchange uses the data contained in the Plan Benefit Template (PBT) to map enrollees. The PBT does not include the product network type. The PBT includes the plan type. In Washington there are four plan types that may be offered on the Health Benefit Exchange. Those include: Health Maintenance Organization (HMO); Point-of-Service plan (POS); Preferred Provider Organization (PPO); and Exclusive Provider Organization (EPO).

  • If there is one QHP available at the enrollee's same metal level and same plan type, map to that plan. 

Hierarchy two

If there are no QHPs with the enrollee’s same metal tier and same plan type available, the Health Benefit Exchange will map the enrollee to a QHP with the same metal tier under a different, similar plan type** and with the lowest enrollee costs, taking into consideration both annualized premium and annual deductible.

**The federal guidance did not describe how it would determine if a different plan type was similar to an enrollee’s current plan type. We have determined the following hierarchy for how the Health Benefit Exchange will determine the similar plan type when an enrollee’s same plan type is not available within the same metal level.

Hierarchy of similar plan type if enrollee’s same plan type is not available:

  • If the enrollee was enrolled in a PPO first attempt to map to a POS. If no POS is available, map to an EPO. If no EPO is available, map to a HMO.

  • If the enrollee was enrolled in a POS, first attempt to map to a PPO. If no PPO is available, map to an EPO. If no EPO is available map to a HMO.

  • If the enrollee was enrolled in a HMO, first attempt to map to a PPO. If no PPO is available, map to a POS. If no POS is available, map to an EPO.

  • If the enrollee was enrolled in an EPO, first attempt to enroll in a PPO. If no PPO is available, map to a POS. If no POS is available, map to a HMO.

Hierarchy three

If there are no QHPs in the same metal level, the Health Benefit Exchange will map the enrollee to a QHP one metal level lower with the same plan type with the lowest enrollee costs, taking into consideration both annualized premium and annual deductible.

Hierarchy four

If there are no QHPs one metal tier lower with same plan type available, the Health Benefit Exchange will map the enrollee to a QHP that is one metal tier lower with a different, similar plan type with the lowest enrollee costs, taking into consideration both annualized premium and annual deductible.

Hierarchy five

If there are no QHPs one metal tier lower with different plan type available, the Health Benefit Exchange will map the enrollee to a QHP one metal tier higher in the same plan type with the lowest enrollee costs, taking into consideration both annualized premium and annual deductible.

Hierarchy six

If there are no QHPs one metal tier higher with the same plan type available, the Health Benefit Exchange will map the enrollee to a QHP one metal tier higher with a different, similar plan type with the lowest enrollee costs, taking into consideration both annualized premium and annual deductible.

Hierarchy seven

If there are no QHPs one metal tier higher with different plan type available, the Health Benefit Exchange will map the enrollee to a QHP in any metal tier with the same plan type with the lowest enrollee costs, taking into consideration both annualized premium and annual deductible.

Hierarchy eight

If there are no QHPs in any metal tier with same plan type available the Health Benefit Exchange will map the enrollee to a QHP in any metal tier with a different, similar plan type with the lowest enrollee costs, taking into consideration both annualized premium and annual deductible.