How to Efficiently and Effectively Help Consumers Navigate Plan Selection

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Dave Chandra, Senior Policy Analyst, Center on Budget and Policy Priorities | 06.11.15

How to Effectively and Efficiently Help Consumers Navigate Plan Selection

1.  Trends in Marketplace QHPs 2.  Analyzing QHPs in your Region 3.  Assisting Consumers in Plan Selection - Demonstration 4.  Assisting Consumers in Plan Selection - Interactive

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2 Presentation Overview

Trends in Marketplace QHPs

Overview of Marketplace Health Plan Elements

1.  Premium 2.  Cost Sharing

– Deductible – Co-pays/Co-insurance – Out-of-Pocket Maximum

3.  Benefits/Drug Formulary 4.  Provider Network

4

Copays

Fixed dollar amount per visit or per day paid by the enrollee.

Coinsurance

Percent of a medical fee/bill paid by the enrollee

Copays and Coinsurance

Overview

Source: HealthCare.gov, Kaiser Permanente KP VA 0/20/Dental and KP VA 1000/20/Dental Gold Plans for Fairfax County, VA

5

Increase of Coinsurance in QHPs 6

Source: HealthCare.gov, Highmark Health Savings Blue PPO 2750 Silver plan for Westmoreland County, PA

Copays and Coinsurance

Prescription Drug Copay Tiers

7

Source: HealthCare.gov, UPMC Advantage Value Silver Select plan for Westmoreland County, PA

Additional Tiering of Prescription Drug Copays 8

Source: Summary of Benefits and Coverage for Humana Silver 4600/AusRn HMOx in Travis County, TX

Additional Tiering of Prescription Drug Copays 9

SourceHumana Silver 4600/AusRn HMOx in Travis County, TX

Services/Copays Exempt from the Deductible 10

Source: HealthCare.gov, Anthem HealthKeepers Silver X 3350 15 plan for Fairfax County, VA

deduc%ble applies

Services/Copays Exempt from the Deductible 11

Source: HealthCare.gov, Anthem HealthKeepers Silver X 3350 15 plan for Fairfax County, VA

deduc%ble does not apply

HSA vs. Non-HSA Plans 12

Source: HealthCare.gov, Kaiser Permanente Bronze 4500/5-‐/HAS/Dental/Ped Dental and Bronze 4500/5-‐/Dental/Ped Dental plans in Fairfax County VA

“3 Step Copay” (Copay/Deductible/Coinsurance) 13

Source: Summary of Benefits and Coverage for Anthem HealthKeepers Bronze X 4500 35 in Fairfax County, VA

“3 Step Copay” (Copay/Deductible/Coinsurance) 14

Source: HealthCare.gov, Anthem HealthKeepers Bronze X 4500 35 in Fairfax County, VA

Cost Sharing Reduction (CSR) Plans 15

FPL% Silver Plan Eligibility

< 150% 94% variant

151% -‐ 200% 87% variant

201% -‐ 250% 73% variant

> 251% 70% base plan



Essential Health Bene!ts 18

Pediatric Dental Bene!t

Source: healthcare.gov, InnovaRon Health-‐Aetna INOVA Silver $10 Copay plan and Kaiser Permanente VA Silver 1750/25%/HSA/Dental/Ped Dental plan for Fairfax County, VA

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Essential Health Bene!ts

Other Covered Services

20

Source: Summary of Benefits and Coverage for New Mexico Health ConnecRons Healthy Connect Bronze HMO in Albuquerque, NM

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Type Name PCP Required?

Referrals Required?

Out-‐of-‐Network Coverage?

PPO Preferred Provider Organiza%on No No Yes

POS Point of Service Yes Maybe Yes

HMO Health Maintenance Organiza%on Yes Yes No*

EPO Exclusive Provider Organiza%on No No No*

*except for emergency care

Health Plan Network Types

QHPs with Narrow Provider Networks

Health plans are using narrow provider networks to keep costs down

22

QHPs with Tiered Networks 23

Source: Plan Brochure for Independence Blue Cross HMO Silver ProacRve Plan in Philadelphia County, PA

Tiered Provider Networks 24

Source: Summary of Benefits and Coverage for Independence Blue Cross HMO Silver ProacRve Plan in Philadelphia County, PA

Confusion and Inaccuracies in Provider Directories 25

Source: HealthCare.gov and Provider Search site for BlueCross BlueShield BlueCare SoluRons Plan in Sedgwick County, KS

Preparing for Open Enrollment III

Analyzing QHPs in your Region

Comparing 2014 and 2015 Marketplace Plans 27

Source: ProPublica, h`p://projects.propublica.org/aca-‐enrollment/#

Comparing 2014 and 2015 Marketplace Plans 28

Source: ProPublica, h`p://projects.propublica.org/aca-‐enrollment/#

Analyzing Changes to QHPs in Your Region 29

Comparing QHPs in Your Region 30

Comparing QHPs in Your Region – Additional Bene!ts 31

Service CareFirst BCBS Innova%on Health

Kaiser Permanente

Acupuncture Bariatric Surgery X X ChiropracCc Care X X X CosmeCc Surgery Coverage Outside the U.S. X Dental Care for Adults X Dental Care for Children X Hearing Aids Hearing Aids InferClity Treatment X Long-‐Term/Custodial Nursing Home Care Non-‐Emergency Care when Traveling Outside the US X

Private-‐Duty Nursing X X X Eye Care for Adults X X RouCne Foot Care RouCne Hearing Tests X Weight Loss Programs

Demonstration

Assisting Consumers in Plan Selection

CBPP Marketplace Plan Comparison Worksheet

available at: hQp://

www.healthreformbeyondthebasics.org/marketplace-‐plan-‐comparison-‐worksheet/

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Scenario 1: James and Ann (married couple) 34

James Ann

Age 52 45

County Oakland County, MI

Zip Code 48324

Income $0 $23,000

Federal Poverty Level 144%

Employer coverage? no no

Insurance status uninsured uninsured





Applicant Name: Tax Credit (monthly): Date:

Number of people in the plan: Eligible for cost-‐sharing reducCons? □ No □ 73% □ 87% □ 94%

Marketplace Plan Comparison Worksheet

Option 1 Option 2 Option 3

Insurance company

Health plan name

Metal tier (Bronze, Silver, Gold, Platinum)

Plan type (HMO, PPO, POS, EPO, or other)

Monthly premium (after tax credit)


Applicant Name: James and Ann Tax Credit (monthly): $549.66 Date: 6/11/15

Number of people in the plan: 2 Eligible for cost-‐sharing reducCons? □ No □ 73% □ 87% ý 94%



Insurance company

Health plan name




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Copays/Coinsurance Amount Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes) Deductible applies? (check if yes)

Primary Care Provider (PCP) visit

Specialist visit

Pres

crip

tions

Generic drugs

Preferred brand name drugs

Non-preferred brand name drugs

Specialty drugs

Emergency Room (ER) visit

Inpatient hospital stay

Other service:

Other service:


Insurance company

Health plan name



Deductible (medical/drug or combined)

Out-of-Pocket Maximum (OOP Max)

Health Care Providers In Network/Covered? In Network/Covered? In Network/Covered?

Current doctor/provider:

Other provider or hospital:

Current prescription drugs:

Scenario 1: James and Ann (married couple)

41



Specialist visit

Pres

crip

tions

Generic drugs



Specialty drugs



Other service: Laboratory Services

Other service: X-rays and Diagnostic Imaging


Insurance company

Health plan name












44 Scenario 1: James and Ann (married couple)



47



Specialist visit

Pres

crip

tions

Generic drugs



Specialty drugs






Insurance company

Health plan name










48



Specialist visit

Pres

crip

tions

Generic drugs



Specialty drugs






Insurance company Humana

Health plan name Silver 4600/Detroit HMOx

Plan type (HMO, PPO, POS, EPO, or other) HMO

Monthly premium (after tax credit) $36

Deductible (medical/drug or combined) $1,000 (combined)

Out-of-Pocket Maximum (OOP Max) $1,500






49


Primary Care Provider (PCP) visit $25

Specialist visit $35

Pres

crip

tions

Generic drugs $17*

Preferred brand name drugs $50 ü

Non-preferred brand name drugs 50% ü

Specialty drugs 50% ü

Emergency Room (ER) visit 20% ü

Inpatient hospital stay 20% ü

Other service: Laboratory Services 20% ü

Other service: X-rays and Diagnostic Imaging 20% ü


Insurance company Humana

Health plan name Silver 4600/Detroit HMOx

Plan type (HMO, PPO, POS, EPO, or other) HMO


Deductible (medical/drug or combined) $1,000 (combined)

Out-of-Pocket Maximum (OOP Max) $1,500






50


Primary Care Provider (PCP) visit $25 $10

Specialist visit $35 $30 ü

Pres

crip

tions

Generic drugs $17* 1A - $4, 1B - $20

Preferred brand name drugs $50 ü 25% ü

Non-preferred brand name drugs 50% ü 50% ü

Specialty drugs 50% ü 20% ü

Emergency Room (ER) visit 20% ü $100/10% ü

Inpatient hospital stay 20% ü 10% ü

Other service: Laboratory Services 20% ü no charge ü

Other service: X-rays and Diagnostic Imaging 20% ü 10% ü


Insurance company Humana Blue Care Network of MI

Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver

Plan type (HMO, PPO, POS, EPO, or other) HMO HMO

Monthly premium (after tax credit) $36 $73

Deductible (medical/drug or combined) $1,000 (combined) $350 (combined)

Out-of-Pocket Maximum (OOP Max) $1,500 $1,000






51


Primary Care Provider (PCP) visit $25 $10 $10 n/a

Specialist visit $35 $30 ü $20 n/a

Pres

crip

tions

Generic drugs $17* 1A - $4, 1B - $20 no charge n/a

Preferred brand name drugs $50 ü 25% ü $15 n/a

Non-preferred brand name drugs 50% ü 50% ü $50 n/a

Specialty drugs 50% ü 20% ü $50 n/a

Emergency Room (ER) visit 20% ü $100/10% ü $75 n/a

Inpatient hospital stay 20% ü 10% ü no charge n/a

Other service: Laboratory Services 20% ü no charge ü no charge n/a

Other service: X-rays and Diagnostic Imaging 20% ü 10% ü $20 n/a


Insurance company Humana Blue Care Network of MI Total Health Care USA

Health plan name Silver 4600/Detroit HMOx Metro Detroit HMO Silver Totally You (Silver)

Plan type (HMO, PPO, POS, EPO, or other) HMO HMO HMO

Monthly premium (after tax credit) $36 $73 $96

Deductible (medical/drug or combined) $1,000 (combined) $350 (combined) $0

Out-of-Pocket Maximum (OOP Max) $1,500 $1,000 $1,500






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Pres

crip

tions

















Current doctor/provider: D. Willens, MD




53




Pres

crip

tions


















Other provider or hospital: # of oncologists



54




Pres

crip

tions



















Current prescription drugs: metformin









62




Pres

crip

tions





















63




Pres

crip

tions

















Current doctor/provider: D. Willens, MD û û û






66




Pres

crip

tions





















67




Pres

crip

tions


















Other provider or hospital: # of oncologists 33 (10 mi.), 69 (20 mi.) 49 (10 mi.), 174 (25 mi.) 17 (10 mi.), 96 (25 mi.)








73




Pres

crip

tions





















74




Pres

crip

tions



















Current prescription drugs: metformin yes (tier 1 & 2) yes (tier 1A) yes (tier 1 & 3)


•  Cheapest monthly payment? •  Manageable deductible? •  Low copays/coinsurance? •  Having “first dollar” coverage? (i.e.

some services exempt from the deductible)?

•  Prescription drugs covered? •  Current doctor in network? •  Size of network?

Identify James’s and Ann’s Priorities for Insurance 75

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*Jennifer can be claimed as a tax dependent as a qualifying relaRve because she is receives more than half of her support from her parents and makes less than $3,950

Scenario 2: the Green Family (family of 5)

Rosa Dan Jennifer* Kristy Cara

Age 43 43 20 16 10

County (Zip Code) Greenville County, SC (29607)

Income $25,000 $20,000 $0 $0 $0

FPL 161 %FPL

Employer coverage no no no no no

Insurance status uninsured uninsured uninsured on Medicaid on Medicaid

77 Scenario 2: the Green Family (family of 5)

Scenario 2: the Green Family (family of 5) 78

Applicant Name: Tax Credit (monthly): Date:

Number of people in the plan: Eligible for cost-‐sharing reducCons? □ No □ 73% □ 87% □ 94%



Insurance company

Health plan name





Applicant Name: Rosa, Dan, Jennifer Tax Credit (monthly): $548.80 Date: 6/11/15

Number of people in the plan: 3 Eligible for cost-‐sharing reducCons? □ No □ 73% ý 87% □ 94%



Insurance company

Health plan name








84



Specialist visit

Pres

crip

tions

Generic drugs



Specialty drugs




Insurance company

Health plan name



Deductible (in-network/out-of-network)

OOP Maximum (in-network/out-of-network)

Other Considerations

Other Consideration:




85


Primary Care Provider (PCP) visit no charge ü

Specialist visit no charge ü

Pres

crip

tions

Generic drugs no charge ü

Preferred brand name drugs no charge ü

Non-preferred brand name drugs no charge ü

Specialty drugs no charge ü

Emergency Room (ER) visit no charge ü

Inpatient hospital stay no charge ü


Insurance company Consumers’ Choice

Health plan name Bronze HDP 1

Plan type (HMO, PPO, POS, EPO, or other) EPO


Deductible (in-network/out-of-network) $11,000

OOP Maximum (in-network/out-of-network) $11,000






86


Primary Care Provider (PCP) visit no charge ü $40

Specialist visit no charge ü $150

Pres

crip

tions

Generic drugs no charge ü $20

Preferred brand name drugs no charge ü $80

Non-preferred brand name drugs no charge ü $150

Specialty drugs no charge ü 20% ü

Emergency Room (ER) visit no charge ü 20% ü

Inpatient hospital stay no charge ü 20% ü


Insurance company Consumers’ Choice Consumers’ Choice

Health plan name Bronze HDP 1 Bronze 10

Plan type (HMO, PPO, POS, EPO, or other) EPO EPO


Deductible (in-network/out-of-network) $11,000 $12,600

OOP Maximum (in-network/out-of-network) $11,000 $13,200






87


Primary Care Provider (PCP) visit no charge ü $40 T1: $15, T2: $50 ~

Specialist visit no charge ü $150 $75 for 1/$75 ~

Pres

crip

tions

Generic drugs no charge ü $20 T1 & 2: $20

Preferred brand name drugs no charge ü $80 T1 & 2: $45 ü

Non-preferred brand name drugs no charge ü $150 T1 & 2: $75 ü

Specialty drugs no charge ü 20% ü T1 & 2: 40% ü

Emergency Room (ER) visit no charge ü 20% ü $250 for 2/$250 ~

Inpatient hospital stay no charge ü 20% ü T1: $250, T2: $500 ü


Insurance company Consumers’ Choice Consumers’ Choice Coventry

Health plan name Bronze HDP 1 Bronze 10 Bronze $15 Copay Upstate

Plan type (HMO, PPO, POS, EPO, or other) EPO EPO POS


Deductible (in-network/out-of-network) $11,000 $12,600 T1: $10,000/T2: $12,500

OOP Maximum (in-network/out-of-network) $11,000 $13,200 $13,200






88




Pres

crip

tions















Other Consideration: out-of-network coverage? û û ü




89




Pres

crip

tions
















Other Consideration: Spanish speaking PCPs







94




Pres

crip

tions
















Other Consideration: Spanish speaking PCPs



95




Pres

crip

tions
















Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) T1: 46, T2: 15 (10 mi.)





98




Pres

crip

tions
















Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) T1: 46, T2: 15 (10 mi.)


99



Specialist visit no charge ü $150

Pres

crip

tions


Preferred brand name drugs no charge ü $80

Non-preferred brand name drugs no charge ü $150






Health plan name Bronze HDP 1 Bronze 10






Other Consideration: out-of-network coverage? û û

Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.)


100


Primary Care Provider (PCP) visit no charge ü $40 $10

Specialist visit no charge ü $150 20% ü

Pres

crip

tions

Generic drugs no charge ü $20 $10

Preferred brand name drugs no charge ü $80 20% ü

Non-preferred brand name drugs no charge ü $150 20% ü

Specialty drugs no charge ü 20% ü 20% ü

Emergency Room (ER) visit no charge ü 20% ü 20% ü

Inpatient hospital stay no charge ü 20% ü 20% ü


Insurance company Consumers’ Choice Consumers’ Choice Consumers’ Choice

Health plan name Bronze HDP 1 Bronze 10 Silver 10

Plan type (HMO, PPO, POS, EPO, or other) EPO EPO EPO


Deductible (in-network/out-of-network) $11,000 $12,600 $1,000



Other Consideration: out-of-network coverage? û û û

Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.)


101

Copays/Coinsurance Amount Amount Deductible applies? (check if yes) Deductible applies? (check if yes)


Specialist visit no charge ü 20% ü

Pres

crip

tions


Preferred brand name drugs no charge ü 20% ü

Non-preferred brand name drugs no charge ü 20% ü




Option 1 Option 3


Health plan name Bronze HDP 1 Silver 10






Other Consideration: out-of-network coverage? û û

Other Consideration: Spanish speaking PCPs 19 (10 mi.) 26 (20 mi.) 19 (10 mi.) 26 (20 mi.)


$0 $2,004

Annual Cost Annual Cost

$6,400

$6,400

$40

$480

$4,124

$600

Health care needs: •  PCP checkup every 3 months ($120/visit) •  Four generic prescriptions per month ($40 retail) •  Hospitalization ($4,000 bill)

$1,000

Identify the Green Family’s Priorities for Insurance

•  Cheapest monthly payment? •  Manageable deductible? •  Low copays/coinsurance? •  Having “first dollar” coverage? (i.e. some

services exempt from the deductible?) •  Current doctor in network? •  Size of network •  Prescription drugs covered? •  Out-of-network coverage? •  Language spoken by providers? •  Lowest overall annual cost (premiums +

anticipated cost-sharing)

102

Interactive Exercise

Assisting Consumers in Plan Selection

Assisting Consumers in Plan Selection 10

4

Scenario 1: Sasha (Tampa Bay Lightning Fan) 105

Sasha

Age 37

County Hillsborough County, FL

Zip Code 33601

Income $25,000


Employer coverage? no

APTC $139.62/month

Cost-‐sharing ReducCons? Yes (Silver 73%)

Priorities •  Very concerned about cost •  Doesn’t have a specific doctor •  Has one prescription medication (generic)

B1 B2

B3 B4

QHPs available to Sasha (Tampa, FL) - Bronze 106

QHPs available to Sasha (Tampa, FL) - Bronze 107

B5 B6

B7

S1 S2

S3 S4

QHPs available to Sasha (Tampa, FL) - Silver 108

S5 S5

S7

QHPs available to Sasha (Tampa, FL) - Silver 109

Scenario 2: Jillian and Michael (Chicago fans) 110

Jillian Michael

Age 55 55

County Cook County, IL

Zip Code 60609

Income $22,800 $7,200


Employer coverage? no no

APTC $603.77/month

Cost-‐sharing ReducCons? Yes (Silver 87%)

Scenario 2: Jillian and Michael (Chicago fans) 111

Contact Info

Dave Chandra Senior Policy Analyst

202-408-1080 [email protected]

For more information and resources, please visit:

www.healthreformbeyondthebasics.org

a project of the Center on Budget and Policy PrioriRes, www.cbpp.org

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How to Efficiently and Effectively Help Consumers Navigate Plan Selection