How to Efficiently and Effectively Help Consumers Navigate Plan Selection

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

exercise

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

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

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

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

Essential Health Bene!ts

Other Covered Services

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

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

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/

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

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

Generic drugs

Preferred brand name drugs

Non-preferred brand name drugs

Specialty drugs

Emergency Room (ER) visit

Inpatient hospital stay

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)

Specialist visit

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)

Specialist visit

Generic drugs

Specialty drugs

Insurance company

Health plan name

Specialist visit

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

Primary Care Provider (PCP) visit $25

Specialist visit $35

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

Primary Care Provider (PCP) visit $25 $10

Specialist visit $35 $30 ü

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

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

Specialist visit $35 $30 ü $20 n/a

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

Current doctor/provider: D. Willens, MD

Other provider or hospital: # of oncologists

Current prescription drugs: metformin

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

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

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

*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

Specialist visit

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:

Primary Care Provider (PCP) visit no charge ü

Specialist visit no charge ü

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

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

Specialist visit no charge ü $150

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

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

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

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

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

Other Consideration: Spanish speaking PCPs

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

Specialist visit no charge ü $150

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.)

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

Specialist visit no charge ü $150 20% ü

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.)

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

Specialist visit no charge ü 20% ü

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

$4,124

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)

Interactive Exercise

Assisting Consumers in Plan Selection

Assisting Consumers in Plan Selection 10

Scenario 1: Sasha (Tampa Bay Lightning Fan) 105

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)

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

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

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

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 chandra@cbpp.org

For more information and resources, please visit:

www.healthreformbeyondthebasics.org

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

New Training Resources

•  Highly customized, Action-oriented •  New suite of training services

•  Goal-setting •  Planning •  Coaching •  In-person training

•  FOR MORE INFO – training@enrollamerica.org

How to Efficiently and Effectively Help Consumers Navigate Plan Selection

Healthcare

Transcript of How to Efficiently and Effectively Help Consumers Navigate Plan Selection

SeaFrame: Sustaining Today's Fleet Efficiently and Effectively ...

Effectively Responding to the Rising Challenge of Mental Health & Addictions in Corrections How to Effectively & Efficiently Treat These Issues to Reduce.

AND EFFICIENTLY EFFECTIVELY YOUR EMPLOYEES

How to Effectively & Efficiently Respond to FOI Requests

RBI- In need to act efficiently, effectively and pragmaticallyaicas.in/blog_images/pdf_2016/01-2016.pdf · RBI- In need to act efficiently, effectively and pragmatically ORIAL RBI

Local Unit Leaders How to Work Efficiently and Effectively NPTA June 2013.

Searching Effectively and Efficiently for Accurate Answers ......Searching Effectively and Efficiently for Accurate Answers to Clinical Questions Andrew Schenkel DMD, MS New York University

Manageallpaid search efficiently effectively The right technology to manage all of your paid search campaigns efficiently and effectively across major.

Working Efficiently & Effectively Resource 3 Manufacturing Techniques.

Efficiently & effectively using social media - INSEAD Alumni Association The Netherlands

TOOLS FOR EFFECTIVELY AND EFFICIENTLY MANAGING THE PEER REVIEW PROCESS

How to Efficiently and Effectively Utilize the USDA … to Efficiently and Effectively Utilize the USDA Foods Program Amy Bell and Jeanette Lund Food Distribution Program . CSNA’s

Perform ServiceNow upgrades efficiently and more effectively

How to Effectively and Efficiently Communicate Research ...

Opportunities to manage big data efficiently and effectively

Local Unit Leaders How to Work Efficiently and Effectively

Rbi in need to act efficiently, effectively and pragmatically

Planning More Efficiently & Effectively - NADO.org · PDF filePlanning More Efficiently & Effectively: ... Sustainability/Planning Coordinator, ... üImplementation activities based

How to Track Time and Effort Effectively and Efficiently

TIME MANAGEMENT -Using Time Effectively & Efficiently.