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 Standard Plans Public Option Plans 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 Gold Silver Bronze Range: 76%-82% AV Range: 66%-72% AV Range: 56%-65% AV ▪ 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 *Per Cascade Care legislation, Exchange will require only one of these standard bronze plans 7

Themes o of 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 1. Integrated deductible 2. Separate medical and Rx deductible 9

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 *Estimated average premium changes weighted for enrollment 10

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: OOP A Amo mount P Paid OOP A Amount P Paid b by Bill ll Medical S Medic l Servic ice/Treatment by P Patient ( (2020 2020 Patien ient (Stand ndard Charg rges* Bronze P e Plan) n) 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 $190 $190 $95 $95 COST CO Services shaded in blue are not subject to the deductible 12

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: OOP A Amo mount P Paid OOP A Amount P Paid b by Bill ll Medical S Medic l Servic ice/Treatment by P Patient ( (2020 2020 Patien ient (Stand ndard Charg rges* Bronze P e Plan) n) 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 $190 $190 $190 $190 COST CO Services shaded in blue are not subject to the deductible 13

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) ▪ Rosa’s out-of-pocket spending with the most popular gold plan in Spokane County and the proposed standard gold plan is shown below: OOP A Amo mount P Paid by OOP A Amo mount P Paid by Medical S Medic l Servic ice/Treatment Bill C ll Charges es* Patien ient (Stand ndard G Gold ld Patient ( (2020 Go 2020 Gold P Plan) Plan) n) Plan D n Deduc eductible ible $1,150 $500 $40 copay / visit (5 visits Qua uarterly ly s specia ialis list v visit its $350 /visit $35 copay / visit at copay) $1,627 / Rx $1,150 (deductible) + Preferred Brand nd D Drugs ugs (2 pres escrip iptio ions ns) $55 copay / Rx $70 copay 1 st month; $90 / 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 Services shaded in blue are not subject to the deductible *Rosa would meet the out-of-pocket maximum of $6,500 in January 15

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