Washington Health Benefit Exchange Draft S ft Standard P Plans for - - PowerPoint PPT Presentation

Washington Health Benefit Exchange

Draft S ft Standard P Plans for Public C Comment

Backgr ground: A Affordability C Challenges for Exchange C Consumers

▪ Consumer costs have continued to rise year-over-year ▪ Consumers have difficulty understanding cost-sharing and comparing value of plans ▪ Consumers do not feel like they get a lot for the cost of their health plan ▪ Board interest in investigating affordability solutions – how might we improve consumers’ experience with buying and using health insurance?

2

Casc scade C e Care

Response to rising premiums and deductibles and declining enrollment in the individual market and failure to enact reinsurance

• Standard Plans: Goal to make care more accessible by lowering

deductibles, making cost-sharing more transparent, and providing more services before the deductible.

• Public Option Plans: Goal to make more affordable (lower

premium) options available across the state, that also include additional quality and value requirements

• Subsidy Study: Goal to develop and submit a plan for

implementing premium subsidies through Exchange for individuals up to 500% FPL (report due Nov. 15, 2020)

3

Three Different Types of Health Plans in the Exchange in 2021: Non-Standard Plans, Standard Plans, and Public Option Plans

Non-Standard Plans Standard Plans Public Option Plans

(Standard Plans Plus)

Offered through the Exchange and eligible for federal tax subsidies    Subject to full regulatory review by OIC, including network adequacy and rate review requirements    Adheres to 19 Exchange certification criteria for QHPs    Meets federal actuarial value requirements for metal levels    Includes Essential Health Benefits    Uses plan design with deductibles, co-pays, and co-insurance amounts set by Exchange for each metal level (bronze, silver, gold)   Some services guaranteed to be available before the deductible   Allows consumers to easily compare plans based on premium, network, quality, and customer service   Procured by HCA (Could result in one or more plans per county)  Required to incorporate Bree Collaborative and Health Technology Assessment program recommendations  Caps aggregate provider reimbursement at 160% of Medicare  Subject to a floor on reimbursement for primary care services (135% of Medicare) and reimbursement of rural hospitals (101% of cost)  Requires carriers to offer a bronze plan (in addition to silver and gold)  Carriers required to offer to participate in the Exchange 

4

Exchange Go e Goals f s for C Casc scade e Care

▪ Offer more affordable health plan options for consumers ▪ Grow new enrollment – including those remaining uninsured and those purchasing plans in the outside market ▪ Retaining current enrollment, including unsubsidized enrollees ▪ Strengthen the individual market and its competitiveness, through carrier participation, more valuable product offerings, and overall enrollment

5

Mark rket Co Context f for R r Recommended Pl Plans

▪ Exchange will require 1 standard plan per metal level ▪ We have designed these plans to fit strategically into the context of the current plan landscape ▪ Non-standard plans will continue to be offered alongside standard plans, so the standard plans are designed to fit intentionally into the mix of available plan options ▪ Opportunity for meaningfully different plans available statewide, with the understanding that current options will still be available

6

Recommended Standard P Plan D Design gns

▪ We released 4 plans for public comment: one gold, one silver, and two bronze plans*

▪ 81% AV gold plan ▪ 71% AV silver plan ▪ 64% AV bronze plan ▪ 62% AV bronze HSA plan

7

Gold

Range: 76%-82% AV

Silver

Range: 66%-72% AV

Bronze

Range: 56%-65% AV

*Per Cascade Care legislation, Exchange will require only one of these standard bronze plans

Themes o

• f S

Standard P Plans

▪ All benefits have standard cost sharing (even if not listed in plans) ▪ Goal of providing lower deductibles and access to services before the deductible at each metal level ▪ Standard silver plan maximizes tax credits by setting AV floor for all silver plans and being at high end of range ▪ Utilize co-pays to the extent possible in each metal level to provide predictability and transparency to consumers

8

AVs of Standard Plans i in O Other S States

9

1. Integrated deductible 2. Separate medical and Rx deductible

Estimat mated P Pre remi mium I m Impacts

▪ Wakely estimated how standard plan designs could impact current plan premiums ▪ Premium impacts of recommended plan designs compared to current plans are estimated to result in:

▪ Average increase* of 4.65% at the gold level, up to 8% ▪ Average of increase* of 3.12% at the silver level, up to 7% ▪ Average increase* of 1.40% at the high-AV bronze level, up to 4% ▪ Average decrease* of -2.7% in the HSA bronze plan, up to a decrease of 4%

▪ We will be asking carriers to provide their feedback on estimated premium impacts

10

*Estimated average premium changes weighted for enrollment

Scen enario 1 1

▪ Erica is a 27-year old healthy consultant living in Seattle. Erica typically has no health needs but catches the office bug that takes a turn for the worst and requires a visit to urgent care. ▪ Erica enrolls in a bronze plan

Scen enario 1 1 (continued) ed)

▪ Erica’s out-of-pocket spending with a current bronze bronze plan in King County and the proposed higher- AV (64% AV) standard bronze plan is shown below:

12

Medic Medical S l Servic ice/Treatment Bill ll Charg rges* OOP A Amo mount P Paid by P Patient ( (2020 2020 Bronze P e Plan) n) OOP A Amount P Paid b by Patien ient (Stand ndard Bronze P e Plan) n) Plan D n Deduc eductible ible $8,000 $6,000 Urgent C Care re $185 $185 (deductible) $90 copay Pres escrip iptio ion f n for a ant ntibio ibiotic ic $5 $5 copay $5 copay ERICA CA’S O OUT-OF OF-POCKE KET CO COST $190 $190 $95 $95

Services shaded in blue are not subject to the deductible

Scen enario 1 1 (continued) ed)

▪ Erica’s out-of-pocket spending with a current bronze plan in King County and the proposed standard HSA bronze plan is shown below:

13

Medic Medical S l Servic ice/Treatment Bill ll Charg rges* OOP A Amo mount P Paid by P Patient ( (2020 2020 Bronze P e Plan) n) OOP A Amount P Paid b by Patien ient (Stand ndard HSA B Bronze e Plan) n) Plan D n Deduc eductible ible $5,500 $6,250 Urgent C Care re $185 $185 (deductible) $185 (deductible) Pres escrip iptio ion f n for a ant ntibio ibiotic ic $5 $5 copay $5 (deductible) ERICA CA’S O OUT-OF OF-POCKE KET CO COST $190 $190 $190 $190

Services shaded in blue are not subject to the deductible

Scen enario 2 2

▪ Rosa is a 45-year old cancer survivor living in

• Spokane. Rosa has no other health issues

but needs to see a specialist every three months and takes three drugs daily, one which is a high-cost, specialty drug. ▪ Rosa enrolls in a gold plan because of these prescription needs

14

Scen enario 2 2 (continued) ed)

15

Medic Medical S l Servic ice/Treatment Bill C ll Charges es* OOP A Amo mount P Paid by Patient ( (2020 Go 2020 Gold P Plan) OOP A Amo mount P Paid by Patien ient (Stand ndard G Gold ld Plan) n) Plan D n Deduc eductible ible $1,150 $500 Qua uarterly ly s specia ialis list v visit its $350 /visit $40 copay / visit (5 visits at copay) $35 copay / visit Preferred Brand nd D Drugs ugs (2 pres escrip iptio ions ns) $1,627 / Rx $90 / Rx $1,150 (deductible) + $70 copay 1st month; $55 copay / Rx High gh-cost Drug ug $21,050 / Rx $5,240 coinsurance* $90 copay / Rx ROSA’S O OUT-OF OF-POCK CKET CO COST $6, $6,50 500 / 0 / year $2, $2,54 540 / 0 / year

▪ Rosa’s out-of-pocket spending with the most popular gold plan in Spokane County and the proposed standard gold plan is shown below:

Services shaded in blue are not subject to the deductible *Rosa would meet the out-of-pocket maximum of $6,500 in January

Scen enario 3 3

▪ Marco is a 53-year-old early retiree in Chelan County who has a chronic condition that requires a daily drug, monthly lab tests, and bi-monthly visits to his primary care provider. ▪ Marco enrolls in a silver plan because of his ongoing health needs ▪ In September, Marco experiences an episode and goes to urgent care where he is given a drug to bring his blood levels back to normal. After this incident, Marco schedules an extra appointment with his primary care provider.

16

Scen enario 3 3 (continued) ed)

17

Medic Medical S l Servic ice/Treatment Bill C ll Charges es* OOP A Amo mount P Paid by Patient ( (2020 S 2020 Silver P r Plan) OOP A Amount P Paid by d by P Patien ient (Stand ndard S d Silv lver P Plan) n) Plan D n Deduc eductible ible $7,050 $2,000 Bi Bi-Monthly ly P Primary C Care V e Visit it $106 / visit $30 copay / visit $25 copay / visit Ma Main intenanc nce P Pres escrip iptio ion n (Gene eneric ic) $17 / Rx $15 copay /month $17 copay / month Monthly B Blood T Test $85 / month $85 (deductible) / month $30 copay / month Urgent C Care re $185 $60 copay $60 copay Medic Medicatio ion a n admin inis istered d $150 $50 copay $65 copay Follow

• w-up

up wi with P h Primary C Care P e Provid ider er $106 / visit $30 copay $25 copay MARCO’S O OUT-OF OF-POC OCKET C T COST $1, $1,52 520 $864 $864

▪ Marco’s out-of-pocket spending with the most popular silver plan in Chelan County and the proposed standard silver plan is shown below:

Services shaded in blue are not subject to the deductible

Scen enario 4 4

▪ Taylor is 62-years old, self-employed, and in good health living in Grays Harbor County. He enrolls in a bronze plan because of the premium price and he typically just goes for a check-up. ▪ Taylor only has one carrier in his county, so he picks the plan with the lowest premium ▪ Taylor falls and hears a crack in his arm. After visiting urgent care he learns his arm is broken and he needs to follow up with a specialist.

18

Scen enario 4 4 (continued) ed)

19

▪ Taylor out-of-pocket spending with the lowest- premium bronze plan in Grays Harbor County and the proposed higher-AV standard bronze plan is shown below:

Services shaded in blue are not subject to the deductible

Medic Medical S l Servic ice/Treatment Bill C ll Charges es* OOP A Amo mount P Paid by Patient ( (2020 B 2020 Bronze P Plan) OOP A Amo mount P Paid by Patien ient (Stand ndard B Bronze e Plan) n) Plan D n Deduc eductible ible $6,350 $6,000 Urgent C Care re $185 $60 copay $90 copay Splin lint $120 $120 deductible $120 deductible Pres escrip iptio ion f n for i ibup uprofen n for p pain in $5 $5 deductible $5 copay X-Ray $68 $68 deductible $68 deductible Orthopedic dic v visit it ( (Spec pecia ialis list) $350 $350 deductible $90 copay for specialist visit Casting ing $300 $300 deductible $300 deductible Follow

• w-up

up o

• rtho

hope pedic ic v visit it $350 $350 deductible $90 copay for specialist visit Evalu luatio ion a n and 4 d 4 sessio ions ns o

• f physic

ical l ther herapy $72/evaluation $59/session $308 deductible $308 deductible TAYL YLOR’S O OUT-OF OF-POCK CKET CO COST $1, $1,56 561 $1, $1,07 071

Scen enario 4 4 (continued) ed)

20

▪ Taylor’s out-of-pocket spending with the lowest-premium bronze plan in Grays Harbor County and the proposed standard HSA bronze plan is shown below:

Services shaded in blue are not subject to the deductible

Medic Medical S l Servic ice/Treatment Bill C ll Charges es* OOP A Amo mount P Paid by Patient ( (2020 B 2020 Bronze Plan) n) OOP A Amount P Paid by d by P Patien ient (Standard H HSA B Bronze P e Plan) Plan D n Deduc eductible ible $6,350 $6,250 Urgent C Care re $185 $60 copay $185 deductible Splin lint $120 $120 deductible $120 deductible Pres escrip iptio ion f n for i ibup uprofen n for p pain in $5 $5 deductible $5 deductible X-Ray $68 $68 deductible $68 deductible Orthopedic dic v visit it ( (Spec pecia ialis list) $350 $350 deductible $350 deductible Casting ing $300 $300 deductible $300 deductible Follow

• w-up

up o

• rtho

hope pedic ic v visit it $350 $350 deductible $350 deductible Evalu luatio ion a n and 4 d 4 sessio ions ns o

• f physic

ical l ther herapy $72/evaluation $59/session $308 deductible $308 deductible TAYL YLOR’S O OUT-OF OF-POCK CKET CO COST $1, $1,56 561 $1, $1,68 686

Scen enario 5 5

▪ Maggie and her partner want to grow their family living in Snohomish County. They have a 5-year old healthy daughter and are trying to get pregnant. ▪ During Open Enrollment they think about the increase in health care they will need in 2020. ▪ Maggie and her partner decide to switch from a bronze plan to the silver plan of their current carrier.

21

Scen enario 5 5 (continued) ed)

22

Medic Medical S l Servic ice/Treatment Bill C ll Charges es* OOP A Amount P Paid by d by P Patien ient (2020 S 2020 Silver P r Plan) OOP A Amount P Paid by d by P Patien ient (Stand ndard S d Silv lver P Plan) n) Plan D n Deduc eductible ible $2,000 $2,000 Init itia ial O l Office V Visit it $125 / visit $20 copay (4 visits at copay) $25 copay Prena enatal l l lab t b tests $150 $150 (deductible) $30 copay Office v visits 2 2-4 $125 / visit $20 copay / visit $25 copay / visit Gluc ucose S e Scree eening ing $250 $250 (deductible) $30 copay First trimester u ultrasound $158 $158 (deductible) $60 copay Office v visits 5 5-11 11 $350 $1,442 (deductible)* $302 coinsurance $25 copay / visit Third t trimester l lab t tes ests a at 9th visit it $150 $45 coinsurance $30 copay Ultrasound a at 9th visit $289 $87 coinsurance $60 copay Labo bor a and d Deliv liver ery $11,129 $3,339 coinsurance $2,000 (deductible)** $750 copay x2 days We Well-ba baby v visit it $59/session $0 $0 MAGGIE IE’S O OUT-OF OF-POCKET COS COST $5, $5,85 853 $3, $3,98 985

Services shaded in blue are not subject to the deductible *Maggie hits her deductible at the 9th office visit **Maggie hits her deductible on the first day of her labor and delivery inpatient stay

▪ Maggie’s personal out-of-pocket spending with a popular silver plan in Skagit County and the proposed standard silver plan is shown below:

Next xt S Steps

▪ Public comment period on second draft of standard plans: October 18 - November 18 ▪ Board and stakeholders discuss second draft of standard plans tomorrow ▪ Will ask carriers to help us understand specific pricing impacts on their plan premiums ▪ Final draft of standard plans will incorporate ELT, Board, stakeholder, and public comment feedback and be presented to Board for vote on December 5

23

24