Standing Advisory Committee Meeting August 8, 2019
Agenda 2 p.m. – 2:05 p.m. Welcome & MHBE Executive Update 2:05 p.m. – 2:30 p.m. Affordability Work Group Report 2:30 p.m. – 2:45 p.m. Out-of-Pocket Cost Calculator Initiative 2:45 p.m. – 3:00 p.m. Prescription Drug Search 3:00 p.m. – 3:35 p.m. Draft 2021 Plan Certification Standards: Concepts and Discussion 3:35 p.m. – 3:45 p.m. SHOP Update & Engagement 3:45 p.m. – 3:55 p.m. State Reinsurance Program 3:55 p.m. – 4 p.m. Public Comments 2
Executive Update
Affordability Work Group Report
Figure 1. Factors of health coverage that affect market participation and health systems interaction. 5
Chart 1. Uninsured, non-elderly Maryland adults stratified by income category (by FPL) and age group. 100,000 90,000 80,000 28,600 70,000 60,000 16,400 50,000 5,200 40,000 10,500 5,100 30,000 49,000 8,500 20,000 3,400 31,800 4,800 10,000 19,500 12,700 0 19-34 35-44 45-54 55-64 Age Category 139-300 301-400 400+ SOURCE: Presentation to the Affordability Work Group. (Families USA 2019) 6
Chart 2. The prevalence of chronic disease in the individual market by age groups. SOURCE: Prevalence of chronic disease across age groups. (MHBE 2019) 7
Table 3: Intervention Population #1: Young Adults (18-34) Sub-Group Near Term Long Term General 1. Marketing investment focused on Young Adults Continued marketing investment focused on Young Adults Women 2. Value Plans: Young Adults with a. Evaluate the outcomes of the Value Plans Substance Use b. Marketing investment in Value Plans Disorder/Behavioral 3. Consumer Decision Support Tools: Health needs a. Development of an Out-of-Pocket Cost Calculator b. Development of a plan shopping experience optimized to display service categories customized by the user, or automatically, by age 4. Development of a health literacy program focused on Young Adults 5. Successful implementation of the Maryland Easy Enrollment Health Insurance Program 139% - 400 % FPL 1. A marketing investment focused on Young Adults 1. Establishment of a state-based Eligible for financial 2. The State should commission a study on a supplemental supplemental premium subsidy for assistance premium subsidy for Young Adults that does not modify Young Adults: the existing federal tax credit structure. The study should: a. Utilizing only state funds or, a. Analyze potential interaction with the State b. Utilizing state & federal pass- Reinsurance Program, and federal pass through, for through funds under a 1332 waiver. the following scenarios: i. Supplemental premium subsidy w/ an independent funding source ii. Supplemental premium subsidy w/ funding carved-out from the existing premium assessment under Md. INSURANCE Code Ann. § 6-102. 8
Table 3: Intervention Population #1: Young Adults (18-34) Sub-Group Near Term Long Term 139% - 400 % i. Supplemental premium subsidy under i 1. Establishment of a state-based FPL & ii seeking federal pass through under supplemental premium subsidy for Eligible for a 1332 waiver Young Adults: financial a. Estimate required funding amount & identify a. Utilizing only state funds or, assistance potential funding sources b. Utilizing state & federal pass- b. Project impact of the subsidy on the through funds under a 1332 waiver. individual market for a five- and ten-year time horizon c. Be updated at a later time to account for the implementation of other policies, i.e. the Maryland Easy Enrollment Health Insurance Program 400+% FPL 1. Continuation of the State Reinsurance Program 1. Continuation of the State Ineligible for Reinsurance Program financial 2. Establishment of a state-based assistance supplemental premium subsidy for Young Adults: a. Utilizing only state funds or, b. Utilizing state & federal pass- through funds under a 1332 waiver. 9
Table 4. Intervention Population #2: Individuals with Chronic Diseases Sub-Group Near Term Long Term General 1. Value Plans 1. Continuation of the State Reinsurance Program a. Evaluate the outcomes of the Value Plans b. Study separate medical & drug deductibles and/or generic drugs before deductible i. Requirement within Actuarial Value ranges (+2/- 4) ii. Impact on the utilization and cost-sharing of other benefit categories 2. Chronic Disease Management Programs a. Increase participation in these programs through education/health literacy b. Analysis of State Reinsurance Program claims for conditions that are drivers of claims to the SRP and the prevalence of those conditions c. Promotion of those with diabetes, hypertension, and depression into Care Management Programs d. State-wide coordination of chronic disease management programs and measurements across markets & programs (Medicare & Medicaid) including diabetes prevention programs 3. Consumer Decision Support Tools a. Plan shopping experience that is responsive to consumer’s unique service category needs b. Prescription Drug Search that relays cost sharing, limitations/ exclusions, prior authorizations, and consumer protections for formulary changes 10
Table 4. Intervention Population #2: Individuals with Chronic Diseases Sub-Group Near Term Long Term General 1. Continuation of the State Reinsurance Program 4. Provider Networks a. Expansion of care coordination for those with chronic diseases b. Expand capacity through telemedicine services c. Improve health literacy for the newly insured with provider selection 11
Opportunity for comment • The Affordability Work Group Report is available for public comment until August 30, 2019. • Link to report: https://www.marylandhbe.com/wp-content/uploads/2019/08/Affordability-Work- Group-Report.pdf • Please submit any comments to MHBE.publiccomments@maryland.gov. 12
Out of Pocket Cost Calculator Initiative
What is an Out of Pocket Cost Calculator • Out of pocket costs include deductibles, coinsurance, and copayments for covered services, plus all costs for services that are not covered • Consumer support decision tools such as out of pocket cost calculators (OOPCC) can assist with comparing plans based on estimated total healthcare costs for a year including premiums, medications, copays, coinsurance and other costs not paid by health insurance • The tool is intended to only be an estimate of general costs, and not a full decision support tool such as in-person assistance 14
History • Out-of-pocket Calculator implemented in 2014 HIX • Noted by issuers and stakeholders as yielding incorrect results • Created by Connecture as a part of the HIX Plan Management “CAP” Module • Out-of-pocket Calculator not included in the HBX • The 2019 Affordability Work Group included a robust Out-of-Pocket Cost Calculator as an important consumer decision support tool to ensure informed enrollment into coverage. • Individuals w/ Chronic Diseases • Young Adults 15
Actions Taken Towards Implementation • State-Based Marketplace discussion facilitated by National Academy for State Health Policy • Discussion with Colorado Health to determine data utilized and formulary • All-payer claims data received from Center for Improving Value in Health Care (CIVHC) • Doctor/outpatient/hospital costs are calculated based on an average for each age group, health usage level, and zip code • Yearly cost estimate= (Monthly premium-Estimated APTC) + (Out of pocket costs) • Out of pocket costs =covered medications, doctors visits, outpatient visits, hospital procedures • Discussion with CMS on effectiveness of implementation • Discussion with Maryland Health Care Commission to obtain claims data 16
SBM OOPCC – Discussion Goals Lower the number of clicks to find the best place Ensure that consumers evaluate plans on factors other than premium Simplify the plan selection process Approaches Connecticut • Asks consumer 5 questions – categorizes consumers into 4 different levels of utilization (high, medium, low, and no costs) California • With questions consumer is sorted into high, medium, and low usage. • Consumers can sort based off calculated OOPCs Minnesota • Consumer questions determine expected utilization and services Display California • Differences Research found that consumers enjoy seeing a dollar amount DC • Research was inconclusive Connecticut • Uses dollar sign due to the tool being based off actuarial models, reflective of the variability of utilization Utilization Connecticut • Originally OOPCC was external to plan shopping: 18,000 – 20,000 users • After integration: 50,000 users (110,000 total enrollees) • Noted usage by broker community DC • OOPCC tool in front of the application • 32,000 users (30% of population) 17 • 92% of users go through the tool
SBM OOPCC – Prescription Drug Tool • All states found that Prescription Drug search was a value-add to their consumer decision support toolkit • Note: importance for enrollees with chronic conditions, i.e. utilization of multiple prescription drugs • Note: ensure timeliness of data with quarterly carrier data submissions • States are mixed with the inclusion of the Prescription Drug Search results in determination of OOPC 18
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