For Insurers

Mapping hierarchy for pediatric dental plans

Washington state pediatric dental auto-reenrollment mapping hierarchy for Plan Year 2018

Hierarchy one Priority enrollment

First, the Health Benefit Exchange will determine an enrollee’s mapped plan based on the following criteria:

  • If the enrollee’s same metal level/level of coverage is available and if the enrollee’s same plan type* is available, the Exchange will then map based on the lowest premium.

* The 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 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)

Hierarchy two

If there are no plans with the enrollee’s same metal level/level of coverage and same plan type available, the Health Benefit Exchange will map enrollees based on the following criteria:

  • The enrollee will be mapped to a plan with the same metal level/level of coverage under a different, similar plan type** and with the lowest premium

**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 plans in the same metal level/level of coverage with a different plan type, the Health Benefit Exchange will map enrollees based on the following criteria:

  • The enrollee will be mapped to a plan one level lower with the same plan type with the lowest premium

Hierarchy four

If there are no plans one metal level/coverage level lower with same plan type available,
the Health Benefit Exchange will map the enrollee to a plan that is one coverage level lower
with a different, similar plan type with the lowest premium.

Hierarchy five

If there are no plans one metal level/coverage level lower with different plan type available,
the Health Benefit Exchange will map the enrollee to a plan one metal level/coverage level
higher in the same plan type with the lowest premium.

Hierarchy six

If there are no plans one metal level/coverage level higher with different plan type
available, the Health Benefit Exchange will map the enrollee to a plan one metal
level/coverage level higher with a different, similar plan type with the lowest premium.

Hierarchy seven

If there are no plans one metal level/coverage level higher with different plan type
available, the Health Benefit Exchange will map the enrollee to a plan in any metal
level/level of coverage with the same plan type with the lowest premium.

Hierarchy eight

If there are no plans in any metal level/level of coverage with same plan type available the
Health Benefit Exchange will map the enrollee to a plan in any metal level/level of coverage
with a different, similar plan type with the lowest premium.