Standing Advisory Committee Meeting August 8, 2019 Agenda 2 p.m. - - PowerPoint PPT Presentation
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
August 8, 2019
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
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Figure 1. Factors of health coverage that affect market participation and health systems interaction.
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Chart 1. Uninsured, non-elderly Maryland adults stratified by income category (by FPL) and age group.
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49,000 31,800 19,500 12,700 16,400 10,500 8,500 4,800 28,600 5,200 5,100 3,400 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 100,000 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)
Chart 2. The prevalence of chronic disease in the individual market by age groups.
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SOURCE: Prevalence of chronic disease across age groups. (MHBE 2019)
Table 3: Intervention Population #1: Young Adults (18-34)
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Sub-Group Near Term Long Term
General Women Young Adults with Substance Use Disorder/Behavioral Health needs 1. Marketing investment focused on Young Adults 2. Value Plans:
3. Consumer Decision Support Tools:
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 Continued marketing investment focused on Young Adults 139% - 400 % FPL Eligible for financial assistance 1. A marketing investment focused on Young Adults 2. The State should commission a study on a supplemental premium subsidy for Young Adults that does not modify the existing federal tax credit structure. The study should:
Reinsurance Program, and federal pass through, for the following scenarios:
independent funding source
carved-out from the existing premium assessment under Md. INSURANCE Code
1. Establishment of a state-based supplemental premium subsidy for Young Adults:
through funds under a 1332 waiver.
Table 3: Intervention Population #1: Young Adults (18-34)
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Sub-Group Near Term Long Term 139% - 400 % FPL Eligible for financial assistance
& ii seeking federal pass through under a 1332 waiver
potential funding sources
individual market for a five- and ten-year time horizon
implementation of other policies, i.e. the Maryland Easy Enrollment Health Insurance Program 1. Establishment of a state-based supplemental premium subsidy for Young Adults:
through funds under a 1332 waiver. 400+% FPL Ineligible for financial assistance 1. Continuation of the State Reinsurance Program 1. Continuation of the State Reinsurance Program 2. Establishment of a state-based supplemental premium subsidy for Young Adults:
through funds under a 1332 waiver.
Table 4. Intervention Population #2: Individuals with Chronic Diseases
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Sub-Group Near Term Long Term
General 1. Value Plans
generic drugs before deductible
4)
2. Chronic Disease Management Programs
education/health literacy
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
management programs and measurements across markets & programs (Medicare & Medicaid) including diabetes prevention programs 3. Consumer Decision Support Tools
consumer’s unique service category needs
limitations/ exclusions, prior authorizations, and consumer protections for formulary changes 1. Continuation of the State Reinsurance Program
Table 4. Intervention Population #2: Individuals with Chronic Diseases
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Sub-Group Near Term Long Term
General 4. Provider Networks
diseases
c. Improve health literacy for the newly insured with provider selection 1. Continuation of the State Reinsurance Program
Group-Report.pdf
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plus all costs for services that are not covered
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
tool such as in-person assistance
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important consumer decision support tool to ensure informed enrollment into coverage.
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health usage level, and zip code
procedures
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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
medium, low, and no costs) California
Minnesota
Display Differences California
DC
Connecticut
utilization Utilization Connecticut
DC
support toolkit
prescription drugs
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utilize feature when applying for coverage
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cost estimation algorithm was supported by internal stakeholders
until August 30, 2019:
technical expertise) to develop an algorithm for the OOPCC utilizing the data fields in the (APCD)
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consumer must pay, and what alternative drugs may be covered, can make a difference in plan shopping
when making any of the following changes to information provided in the Prescription Drug
the DC Health Link database
plans in anonymous browsing
their enrolled plan in their Account Dashboard in the consumer portal
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Search Page
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Results Page
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29 SOURCE: “The Most Important Health Insurance Chart You’ll Ever See,” The Motley Fool, Keith Spreights, 09/05/17
1. Lower premiums and reduce consumer exposure to health care costs:
the individual market
potential modifications to the State Benchmark Plan
2. Increase consumer choice
3. Expand access to care
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services:
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1. Build off improvements in 2020. 2. Establish reasonable consumer expectations for out-of-pocket costs. 3. Align consumer incentives for health care service utilization. 4. Increase enrollee effectuation rates in the individual marketplace. 5. Align carrier incentives to manage members with high costs. 6. Increase access to stand-alone dental coverage through Maryland Health Connection.
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34 16.30% 11.40% 5.20% 15.60% 11.90% 4.70% 14.00% 9.00% 5.00% 14.00% 9.00% 4.00% 0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% 16.00% 18.00% Hypertension Diabetes Depression On-Exchange 2015 On-Exchange 2016 All Markets 2015 All Markets 2016
SOURCE: Spending and Use Among Maryland’s Privately Insured (MHCC 2018 & 2019)
2016 – 2017 Drivers of Spending Growth in the Individual Market.
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SOURCE: Spending and Use Among Maryland’s Privately Insured (MHCC 2019)
2015-2017 Prescription Drug PMPM by Drug Type, Individual Market.
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SOURCE: Spending and Use Among Maryland’s Privately Insured (MHCC 2019)
2015-2017 Prescription Drug Utilization by Drug Type, Individual Market.
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SOURCE: Spending and Use Among Maryland’s Privately Insured (MHCC 2019)
2015-2017 Prescription Drug Costs by Drug Type, Individual Market.
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SOURCE: Spending and Use Among Maryland’s Privately Insured (MHCC 2019)
covered before deductible by a high-deductible health plan to include certain services for certain chronic diseases.
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2019-45 to non-HDHP qualified health plans in the individual market.
pocket costs for enrollees with chronic diseases, and align individual market plans with state- wide population health initiatives.
1. BROAD: Apply the HDHP Parity Rule to all non-HDHP QHPs. 2. NARROW: Apply the HDHP Parity Rule to all Value Plans.
1. Impact to premiums and actuarial value
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Insurance Design concepts and promote medical adherence.
costs while promoting cost-sharing structures that: 1. Increase the use of high-value care. 2. Decrease the use of low-value care. 3. Limit premium increases attributable to increased actuarial value.
1. Increase market participation with the availability of high value plans. 2. Align products in the individual market with state-wide initiatives under the Total Cost of Care Waiver. 3. Create incentives for value-based product innovation
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YEAR 2020: Implement “Value” plans with deductible and before deductible service requirements.
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Requirements Bronze Silver Gold Minimum offering Issuer must offer at least 1 “Value” plan. Issuer must offer at least 1 “Value” plan. Issuer must offer at least 1 “Value” plan. Branding Required for 2020. Optional. Optional. Deductible ceiling No requirement. Lower deductibles are encouraged. $2500 or less. $1000 or less. Services Before Deductible Issuer may allocate no less than three office visits across the following settings: Primary Care Visit (not including preventive care) Urgent Care Visit Specialist Visit Primary Care Visit Urgent Care Visit Specialist Care Visit Laboratory Tests X-rays and Diagnostics Imaging Generic Drugs* Primary Care Visit Urgent Care Visit Specialist Care Visit Laboratory Tests X-rays and Diagnostics Imaging Generic Drugs
*Encouraged.
YEAR 2021: No changes for the Value Bronze Plan. Limited modifications to the Value Silver and Value Gold Plans.
encouraged.
1. Increased cost sharing for Specialist Care Visit, Laboratory Services, and X-rays and Diagnostics. 2. Limitations for Laboratory Services and X-rays and Diagnostics. 3. Exclusion of X-Rays and Diagnostics or Laboratory Services from Before Deductible Services (not recommended).
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YEAR 2021: No changes for the Value Bronze Plan. Limited modifications to the Value Silver and Value Gold Plans.
Generic Drugs.
1. Increased cost sharing for Specialist Care Visit, Laboratory Services, X-rays and Diagnostics, and Imaging. 2. Limitations for Laboratory Services, X-rays and Diagnostics, and Imaging. 3. Exclusion of Imaging from Before Deductible Services.
1. Implement a prescription drug deductible ceiling of no greater than $250. 2. Include Preferred Brand Drugs as a Before Deductible Service.
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Silver and Value Gold Plans. Note: Value Gold does not include modified prescription drug structure.
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Requirements Bronze Silver Gold Minimum offering Issuer must offer at least 1 “Value” plan. Issuer must offer at least 1 “Value” plan. Issuer must offer at least 1 “Value” plan. Branding Required. Required. Required. Deductible ceiling No requirement. Lower deductibles are encouraged. $2500 or less. $1000 or less. Services Before Deductible Issuer may allocate no less than three office visits across the following settings: Primary Care Visit Urgent Care Visit Specialist Visit Primary Care Visit Urgent Care Visit Specialist Care Visit Laboratory Tests*+ X-rays and Diagnostics*+ Generic Drugs Primary Care Visit Urgent Care Visit Generic Drugs Specialist Care Visit Laboratory Tests* X-rays and Diagnostics* Imaging*+
GREEN = Maintain, or decrease, cost sharing from 2020. *May be subject to limitation.
+May be excluded from before deductible services.
YEAR 2022: Deductible Increment Rule Base Year and no change to before deductible services.
Value Gold Plans. For the 2022 Base Year:
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YEAR 2023: Implement Deductible Increment Rule.
and Value Silver plans from the base year.
example:
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PayNow URL, i.e. to allow consumers to pay their first month’s premium at the point of enrollment.
1. Promote market stability through increased member months. 2. Lowers the administrative barriers to access coverage for consumers.
1. When coupled with other enrollment initiatives (the Maryland Easy Enrollment Health Insurance Program) this requirement may increase coverage up-take for target populations. 2. Creates a uniform customer service experience on Maryland Health Connection.
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document if they utilize a Co-pay Accumulator Program for prescription drugs covered in their formulary and provide information on how the program may impact their out-of-pocket costs.
cost their prescription drug. 1. Increase informed decision making.
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1. Determination of eligibility for Medical Assistance Programs. 2. Determination of eligibility for a Qualified Health Plan. 3. New enrollment in the Small Business Health Options Program. 4. Access to an excepted benefits HRA.
Plans offered on Maryland Health Connection.
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metal levels that allows for Composite Rating.
the SHOP.
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experience with plan design development.
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maximum to remaining enrolled members of a QHP policy in instances where the termination
1. Enrollment in Medicare; 2. Enrollment in group coverage; 3. An enrollee is determined ineligible for QHP coverage due to an unresolved citizenship/immigration status inconsistency under 45 CFR 155.315; or 4. Death.
enrollment who would otherwise have to restart contributions under a new QHP policy.
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MHBE indicated that it would explore options to add incentive structures to the SRP to promote claims and utilization management for high cost enrollees.
assessment year) for incentive payments for issues that demonstrate year-over-year lower claims cost growth in proportion to risk: 1. Claims costs and risk scores would be compared year-to-year. 2. After adjusting for enrollee risk and enrollment in cost-sharing reduction plans, plans that demonstrate that their claims cost growth has decreased as compared to the previous year, would be eligible to receive incentive payments. 3. The maximum amount a carrier can receive in payments is 75% of the amount estimated savings identified in the Carrier State Reinsurance Program Accountability Report.
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claims and utilization management for high claim/high risk members.
1. Opportunity to generate additional pass-through to support incentive payments.
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Plans in the individual market.
1. NARROW: Open eligibility to Catastrophic Plans for those older than 30. 2. BROAD: NARROW + The establishment of a Health Expenditure Account (HEA) to be utilized to pay for medical services. HEA would be partially funded with pass-through that would have been allocated to APTC for enrollees that shift from Metal Level into Catastrophic Plans.
1. Catastrophic Risk Pool Implications. 2. Consideration of concurrent implementation of other strategies, i.e. Young Adult Subsidy for metal level plans, that could impact risk pool. 3. Consideration of SRP impact on Catastrophic Plan rates during the waiver.
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until August 30, 2019.
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analysis on several key areas related to the SRP
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be completed by the end of August, and will include:
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subsidy is administered
associations to increase awareness of the SHOP
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local chambers of commerce
discussion of platform development, and goals of the SHAC
availability
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