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COMPILATION OF PUBLIC COMMENTS ON

2 VERSIONS OF COVERAGE FACTS ILLUSTRATIONS

FOR CONSUMER TESTING

From: Ostlund, Steven

Sent: Monday, May 02, 2011 11:48 AM

To: Sung, Jane

Subject: RE: Notice of Public Comment - Coverage Facts

Jane, I compliment the sub-group on excellent work. There appear to be some typos, and

minor oversights that have slipped through.

In Version 1, page 7 first column at the bottom, a paragraph is repeated, and the sixth

bullet under "Important things..." is nearly the same as the third bullet. I think the form

reads better if "you" replaces "the patient" throughout this page, with the obvious

grammatical adjustments. Similarly the first sentence of "Important things..."might better

end with"...of your costs. "rather than"...of costs for any specific policyholder."

In Version 2, page 6, perhaps substitute "You Pay" for "Patient Pays" all three times. On

page 7, consider deleting "you" in the last sentence column 1, insert "as" between "left

your" on line 5 of the text in column 2, insert "what" between "and your" on line 7 of the

text in column 3. In the next section of column 3, perhaps substitute "you would need to

pay" for "consumers could be responsible to pay". Throughout page 7, substitute "you"

for "patient" with appropriate grammatical adjustments.

I believe most of these changes could be made as staff clarifications.

Steven L. Ostlund, FSA, MAAA

Actuary

Alabama State Insurance Department

(334) 240-4424

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Comments on Coverage Facts Labels

Amy Hasselkus, American Speech-Language-Hearing Association (ASHA)

In general, these look really good! I prefer the first page (page 6 of 7 in these documents)

of version 1 because it more clearly outlines cost breakdowns, and is easier to understand.

I think just giving final numbers is too broad and too vague. I also liked the language

level of version 1 better – having a baby vs. maternity, for example. It is much clearer to

say “having a baby.” It will be interesting to see what consumer testing shows.

For the explanation page, however, I tend to like version 2 better. The four column set up

on version 1 is too visually overwhelming and I think the question and answer format on

version 2 is more user-friendly. Again, results of consumer testing will be interesting.

Some specific comments about page 2 of version 2:

Under the first question (“What are coverage examples…?”), I recommend

deleting the first sentence and starting with “A coverage example gives you a

different perspective.” The first sentence doesn’t seem necessary, adds language,

and would need to be tempered a bit anyway since it says how the plan WILL

cover each type of care and that isn’t necessarily true.

Wordsmithing here – under the question “What does the coverage example

show?”, delete the word “left” out of the second sentence so it reads “It also helps

you see what expenses might be your responsibility…”

At the end of the last question about “are there other costs…”, it would be good to

spell out HAS, FSA, and HRA as not everyone knows what those acronyms

mean.

For page 2 of version 1, we need to delete the third italicized example question in the first

column. That question is repeated twice (which plan pays a share of costs that I am

comfortable with, and charges a premium I can afford?).

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Date: May 2, 2011

To: Consumer Information Working Group

From: Lynn Quincy, Consumers Union

Re: Coverage Facts Label Drafts Exposed April 29, 2011

I commend the working group on their tremendous progress on the Coverage Facts Label

(CFL). The CFL is one component of the Summary of Coverage form called for by

Section 2715 of the Affordable Care Act. The CFL could benefit consumers in three

ways:

help them understand how the health plan’s cost-sharing features interact (for

example, help illustrate that copays don’t count towards OOPM- if that’s the

case)

illustrate the high costs associated with some common medical scenarios

(underscoring the importance of good insurance coverage)

allow consumers to compare health plans using a “bottom line” number showing

the insurance payment associated with a medical scenario.

My comments on the CFL are grouped into three sections:

recommended changes to the CFL itself

medical scenarios illustrated by the label

suggested changes to the embedded plan design in order to facilitate consumer

testing

I. Recommended Changes to CFL

Overall, both alternatives are very impressive. It is clear that much work has gone into

creating clear language versions of the CFL. On the whole, I think Version 1 is stronger,

providing more useable information to the consumer and presenting the information in a

self-evident manner. However, I recommend waiting for the results of consumer testing

prior to recommending one version over the other to HHS.

Overarching Comments

In both versions, do we need a statement that explains to consumers why they can use the

examples to compare plans? For example, something like (except that it would be

improved by a plain language expert): You can use the examples to compare health plans

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because the examples were produced using a standard set of assumptions – the only

differences are plan differences in patient cost-sharing. (NOTE: Version two has a pretty

good version of this. “In each example, the treatments and costs of care shown will be the same in all plans. But how much of the costs consumers could be responsible to pay will be different for each plan, depending on its cost sharing rules and benefit limits.”)

Comments Specific to Version 1:

Consider whether “Total Costs” should instead read “Total Care Costs” to be consistent

with the “care costs” table directly below.

I recommend the following changes to clarify the explanatory text on page 7, and reduce

redundancy:

More information about examples of plan coverage: Using these examples You should receive a Summary of Coverage document like this one for each plan you are considering. Compare the examples in the “Examples of plan coverage” sectionfor this plan to the same examples provided for with examples in Summary of Coverage documents for other plans. The treatments and costs of care will be the same for each example. How much each plan pays and how much you pay may differ, depending on the plan’s cost sharing rules and benefit limits. When you compare the examples from each plan you are considering, ask yourself:

Would I be comfortable paying the share

of expenses shown in these examples?

Which plan pays a share of costs that I

am comfortable with, and charges a

premium I can afford?

Which plan pays a share of costs that I

am comfortable with, and charges a

premium I can afford?

Important things to know about these examples These examples are designed to help you compare different plans, but they are not meant to provide a

Comment [LQ1]: I would omit – inconsistent

with our warning that “this isn’t what you will really

pay”

Comment [LQ2]: Duplicate, not needed.

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complete or realisticguaranteed estimate picture of costs for any specific policyholder. While these examples can help show how different plans offer different levels of coverage, this document is not a cost estimator. It cannot be used to estimate costs for an actual condition. The care you would receive for a condition could be different, based on your doctor’s advice, your age, the severity of your condition, the prices your providers charge, and the charges your this plan allows. These examples are based on the following assumptions:

The costs shown don’t include premiums.

The patient’s condition was not an excluded, pre-existing condition. had coverage prior to the condition.

The patient received all services and treatments during the same policy period.

There were no previous medical expenses in this policy period. Out-of-pocket expenses are based only on treating this condition

The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

All treatments begin and end in the same policy year.

Why did patient pay more than the out-of-pocket limit in some examples? When a patient receives treatment that is not covered by the plan, the amount the patient pays does not count toward the out-of-pocket limit (OOP). Also, plans may have

Comment [LQ3]: If they are not realistic, why

should the consumer use them?

Comment [LQ4]: “this plan” ??

Comment [LQ5]: I think you mean to say that the

condition was not an excluded, pre-existing

condition. A patient could go from being uninsured

to insured under the plan and still have these services

covered.

Comment [LQ6]: Is this true for breast cancer?

Comment [LQ7]: Breast cancer spans two policy

years. Reconcile this discrepancy.

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special deductibles that don’t count toward OOP. For example, a plan might limit mental health visits to 8 per year. The breast cancer scenario exceeds that limit, therefore those treatments would not count toward OOP.

For more information If you have additional questions about what this a plan covers, please

call us toll-free at 1-800-XXXXXXX

or visit us at

www.insurancecompany.com.

Choosing a plan: You want a plan that will give you the coverage you need at a cost you can afford. This Summary of Coverage can help you compare plans. Compare the specific coverages and exclusions listed inusing the chart starting on page 2 ( “Common Medical Events”) section. See which plan best meets your needs. Compare the “Examples of plan coverage” to see which plan pays a share you are most comfortable with. Finally consider other costs when comparing plans, such as your premium costs and employer contributions to medical accounts such as HSAs, FSAs, or HRAs. Your agent, broker, or employer can help.

Version 2:

On Page 6:

Using track changes, I’ve indicated proposed changes to the introductory text on page 6:

Here areThese examples showing how this plan might cover your medical care in three situations.

Comment [LQ8]: Will this example change

based on the plan design? If not, I think the last

sentence needs to be more general, like “ In this

case, the patient’s costs for excluded visits would

show up under benefit limits/exclusions. “

Comment [LQ9]: This useful statement should be

the first information on page 1 of the form!

Comment [LQ10]: Because this is how that chart

is referred to on page 1.

Comment [LQ11]: An employer can’t contribute

to an FSA.

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I would move the warning to follow this paragraph “Use these examples to compare different plans and to see, in general, how much insurance protection you might get from each plan.” AND eliminate the first sentence because it was already stated above. So the warning would now read (after the important info symbol):

TImportant Notice: how an

insurance/HMO plan might cover benefitshis is not a cost estimator, and cannot

be used to estimate costs for an actual condition.

On the right hand side of page 6, spell out “amount”, stacking under the word “Allowed”

if needed. The abbreviation may not be clear to all consumers.

Compared to Version 1, there is no way for a consumer to understand how these patient

cost-sharing amounts were derived or to reconcile the totals back to the plan cost-sharing

provisions. Hence, as a consumer tool, the utility is limited. If this version is sent to

testing, consider whether or not additional detail would be available online. If online

detail is available, then indicate this on page 6.

On page 7:

Using track changes and comments, I recommend the following:

Please note that all examples of plan

coverage are based on these assumptions:

These Patient costs don’t include premiums.

The patient had coverage prior to the condition.

The patient received all services and treatments during the same policy period.

There were no previous medical expenses. Out-of-pocket expenses are based only on treating this condition.

The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What are coverage examples and why are they in this summary? The coverage examples on the preceding page show you how this plan will might cover each type of care or servicethese specific services. A coverage example gives you a different perspective. It shows you how this plan might cover treatment for all the services you might need for a certain health

Comment [LQ12]: Elsewhere in the document,

we don’t include “important notice” alongside the

exclamation point in a triangle.

Comment [LQ13]: Please see my comments on

these same bullets above.

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condition. In this document you will see coverage examples that describe care that might be involved for a routine pregnancy, treatment of breast cancer, and diabetes. The examples show you how much of that care the plan might cover, and how much you might be left for you to pay.

What does a coverage example show? For each treatment situation, the example helps you see how deductibles, co-pays, and co-insurance can add up, and how limits or exclusions can affect you. It also helps you see what expenses might be left your responsibility to pay due to benefit exclusions or limits. By showing you this information, the coverage example gives you a general idea of how much insurance protection this policy provides for these specific conditions.

Remaining material on page 7: I found this discussion very clear and useful. Consider

whether some of this should be included in Version 1.

II. Medical Scenarios

Including a medical scenario that was relevant to men (diabetes) will help make the CFL

more useful to consumers. If consumers find these three examples useful, it could be that

additional medical scenarios will be requested. If there is any guidance or questions that

the group would like answered with respect to the scenarios of greatest interest to

consumers, please let me know.

III. Plan Design And Other Changes To Facilitate Testing

I recognized that the group is not soliciting comments on the other aspects of the

Summary of Coverage form. However, inconsistencies and other issues will distract

participants during testing. Our goal in testing is to examine the utility of the CFL in a

“real world setting.” To that end, it will be important to make the included plan design(s)

as believable as possible.

Page Problem Recommended Change

1-7 PPO or HMO? There is conflicting information

regarding plan design. In the top header the

plan design is PPO but in the warning box and

in the detailed Coverage table that starts on

page 2, the design appears to be an HMO

Change header to be HMO

Comment [LQ14]: This is very helpful text but

doesn’t really apply to version 2, where they can’t

see how the specific cost-sharing features affect

“what they pay”. Unless there is a plan to link them

to additional information online, this would have to

be deleted. Consider using in version 1 (my deletions

provide extra space.)

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Page Problem Recommended Change

1 Deductible: is $7500 the family deductible or

the out-of-network deductible?

Follow insurer instructions

to clarify.

1 Overall Deductible: “doesn’t apply to generic

drugs” but the pharmacy deductible appears to

be for generic and brand drugs.

Change to read “doesn’t

apply to generic and brand

drugs”

1 Policy period begins 9/15/2010 yet the

discussion below notes that most deductibles

start January 1.

Change policy period to be

1/1/2011 – 12/31/2011

1 Referral to Specialist: answer not clear Choose yes or no

1 If you use an in-network doctor…the plan will

pay some or all of the costs for covered

services” – This is misleading; many costs

aren’t covered until deductible is reached.

Reword to say “If you use

an in-network doctor or

other health care provider,

your costs may be lower.”

1-3 If you use an in-network doctor…” - it would

be easier on the consumer if the same term were

used on page 1 and pages 2,3. On the example,

the term in-network is changed to

“participating” on pages 2,3.

Use the same term in both

places.

1 OOP limit: is $7500 the family OOPM or the

out-of-network OOPM?

Follow insurer instructions

to clarify.

2 Definitions – the warning box defines

“copayments” but the chart below uses the term

“co-pay.”

Use the term co-pay in the

definition.

2 Definitions “coinsurance” : “it’s” should be its;

however, the article as used in the sentence is

ambiguous. I would omit the final sentence in

this definition as it really defined deductible

(not coinsurance) and is not needed.

Delete sentence or at least

change “it’s” to “its.”

2 Definitions “coinsurance” : not hyphenated in

definitions, hyphenated in table

Make consistent.

2 Final bullet in warning box is ambiguous. Omit for plans where it

doesn’t apply. Reword for

plans where it does apply –

change “may encourage” to

“encourages”

2 Preventive services – if not subject to

deductible, shouldn’t that fact be noted in the

“exceptions” column?

Add note to the exceptions

column

3 The left-hand column, drug section The word “cover” should be

“coverage”

3 Mental Health outpatient provisions – it appears

that patient must pay the full cost (but at

negotiated rates (otherwise it would say not

covered?) and the first eight visits counts

towards the OOPM. Is OOPM even relevant if

If it is correct to say so:

After eight visits, not

covered.

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Page Problem Recommended Change

the plan doesn’t pay anything? This is very hard

to understand.

3 Mental Health / SA section : shading doesn’t

alternate as it does in other sections

Make consistent with other

sections.

2-4 Are instances of 100% coinsurance intended to

be 0% coinsurance (in other words, completely

paid by plan?)

Check these coinsurance

amounts.

4 Excluded Services- it appears that child dental

and vision should be added to the list of

exclusions.

5 Grievance and Appeal rights – is a word

missing? Should it read “…protest denial of

coverage for claims…”

Make wording clearer.

6 The patient’s costs for having a baby seem

inconsistent with the plan provisions

(deductible=$900)

Make the document

consistent. Apply indicated

cost-sharing provisions.

6 Wig Double check that this was

not an excluded benefit.

6 Breast Cancer Scenario – if the mental health

visits exceed annual limits (as suggested by the

discussion on page 7), the patient costs

associated with this should show up under

“benefit limits/exclusions”

Check that patient cost-

sharing for breast cancer is

correct.

A Second Plan Design that Excludes Coverage for Maternity

It is my understanding that a second plan design will be included in the forms released for

testing and that this plan will not cover maternity. I remind the working group that

maternity should then be listed under “exclusions” on page 4.

Also, the working group should convey to the testers how allowed costs/care costs for

maternity will be treated in this illustration. Presumably, the policyholder will not be

entitled to negotiated rates with providers. Hence, the allowed costs provided by HHS for

CFL may not be realistic. Is an additional warning needed?

Thank you for your attention to this long list of concerns.

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Date: May 3, 2011

To: NAIC Consumer Information Working Group

From: Lynn Quincy and Susan Kleimann

Re: Coverage Facts Label Drafts Exposed April 29, 2011

Lynn Quincy is submitting these brief comments on behalf of Susan Kleimann, president

of the Kleimann Communication Group. Kleimann Communication group is a practice

that integrates the design, development, and rigorous testing of consumer documents to

ensure that consumers can use them to make informed decisions. Dr. Kleimann

examined the documents in preparation for consumer testing, and shared these

observations for the working group’s consideration. Much more detailed

recommendations will be forthcoming after consumer testing the next version of these

Coverage Facts documents.

Version #1, Overall

1. The overall design of page 6 pushes the eye to look at the detailed “Care Costs”

and the detailed “You Pay.” The detail of Total costs and the total of what the

plan and what you pay disappears. It seems like this could be made more visual

and visible. This change may have to wait until after the testing.

2. The language on page 7 seems very, very dense. There are just too many words

on the page.

3. More design elements could help guide people to the different elements. For

example, under “Choosing a plan” could be presented as a checklist to give it

more visual interest. But again, perhaps this should happen after the testing.

Version #1, page 6

1. I would remove colons after headings. They don’t add that much, but they do

make the page look a bit more cluttered. So delete colon after “About these

examples of plan coverage” “Care costs” and “You pay.”

2. Under About these examples of plan coverage in paragraph 2, delete “compare

different plans and . . . .” AND change “each plan” to “different plans.”

3. Under “Important” delete “try and” just say “Don’t use these examples to

estimate what your actual costs . . . “

Version #1, page 7

1. Remove colon after “More information about examples of plan coverage”

2. In column one, the italic statements near the bottom of the page, repeats the

second item.

3. In column 2 and 3, in the following assumptions, the verb tense changes: the

first bullet is present, the next set of bullets are in past tense, last bullet is in

present tense. I would make all present tense.

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Version #2, Overall

1. I think that most consumers will not be able to understand what is meant by

“Allowed Amt” If nothing else, we should write out “amount”

2. I would like to have a total dollar amount on the charts, so that consumers can

see the proportion that they are paying as well. You may not be able to show this

and it is something that we can ask about in testing.

3. The language on page 7 still seems very dense. I know that they have tried to

reduce the language level, but it still seems high. Again this may be one of the test

probes.

Version #2, page 6

1. Under “About these examples of plan coverage” remove the colon.

2. In first sentence under same section, edit text to say: These examples show how

this plan might cover your medical care in three situations.”

Version #2, page 7

1. Remove colon after “Questions and answers about examples of plan coverage”

2. In assumptions in first column, same tense problem as in Version #1. I would

make all things present tense.

3. In “What are coverage examples and what are they in this summary?” I would

delete the first sentence. The third sentence in the paragraph basically says the

same thing. In addition, the first sentence seems misleading in “each type of care

or service.” When actually it only does this for the three examples. I know that’s

kind of picky, but the third sentence seems more accurate.

4. I would prefer that the No and Yes was not underlined. It could be made larger and

bolded instead. Again, the underline just adds a kind of visual clutter.

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1310 G Street, N.W.

Washington, D.C. 20005

202.626.4780

Fax 202.626.4833

By electronic mail 3 May 2011 Jane Sung and Jennifer Cook National Association of Insurance Commissioners 444 North Capitol Street, N.W. Suite 701 Washington, D.C. 20001 Re: Public Comment -- Coverage Facts Dear Ms. Sung and Ms. Cook: Please find following comments submitted on behalf of the Blue Cross and Blue Shield Association (BCBSA) on the “coverage facts” documents. BCBSA is a national federation of 39 independent, community-based and locally operated Blue Cross and Blue Shield companies that collectively provide healthcare coverage for nearly 98 million members -- one-in-three Americans. We greatly appreciate the tremendous efforts over many months by the Consumer Information (B) Subgroup to develop the coverage facts. In addition, thank you for this opportunity to provide comments. BCBSA and the Blue Plans believe that consumer testing will help improve the coverage facts documents as well as the underlying “Summary of Benefits and Coverage” (Summary). With that in mind, BCBSA is pleased to inform the Consumer Information Subgroup that it will partner with America’s Health Insurance Plans (AHIP) in undertaking consumer testing of the coverage facts documents. We anticipate additional consumer testing may help to identify which fonts, colors, format, style, etc., are most helpful to consumers and what information is essential in making an appropriate purchasing decision. With that said, we offer the following recommendations for your consideration: Of particular concern to us in both versions is the strong likelihood that a consumer will make the incorrect assumption that the examples are illustrative of actual costs. We strongly recommend revising the section “About these examples of plan coverage:” on page 6 of both versions as follows:

About these examples of plan coverage: Here are examples showing how this plan might cover your medical care in three situations. Use these examples to compare different plans and to see, in general, how much insurance protection you might get from is provided by each plan.

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Important Don’t use these examples to try and estimate what your actual costs would be under this plan. People and their treatment plans vary. The actual care you receive may will be different from these examples, and the cost of that care might will also be different. ? Questions Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com.

Our communications experts tell us that the reader’s eye naturally moves left to right across the top of horizontal documents. With respect to page 7 of both versions, we recommend that the most important subjects be aligned from left to right across the top to take most advantage of the reader’s attention. We also recommend eliminating acronyms -- such as HSA, FSAs, HRAs -- and replacing them with fully spelled phrases to ensure ease of comprehension. In addition, in Version 1, on page 7, the first column includes several references to “For each plan you are considering,” which implies the person is shopping for insurance coverage. A large portion of people receiving this Summary will be employees of employers who offer only one option, so the Consumer Information Subgroup may want to reword accordingly. While we have numerous other suggestions to improve this important document, we agree that the most valuable input will be provided via the consumer testing effort. As such, we have limited our comments to those we believe should be incorporated into the document prior to testing. Again, thank you for this opportunity to comment. I can be reached at david.korsh@bcbsa.com or 202.251.7310 (cell). Sincerely yours,

David I. Korsh Director, State Services

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From: Tracey Moore Both Versions:

1. Because the majority of disclaimers are in the Q&A section, perhaps a note on

page 6 to alert the reader that more important information is provided on the next

page.

2. The plan used in this example has a per-person deductible. The deductible may

not be applicable until the family meets the family deductible. Therefore, in the

Q&A section, this assumption needs to be rewritten:

There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating this condition.

Version #1:

Examples

1. To help clarify further that these are not true costs, replace the headers “Care

costs” with “Sample care costs” in all three examples.

2. To emphasize that the patient costs are illustrative, replace “You pay” with “You

might pay.”

3. The “Important” note/disclaimer is too small. Use larger text and icon to make it

stand out.

Q&A:

1. This Q&A is not fully accurate. Suggest these changes:

Why did the patient pay more than the out-of-pocket limit in some examples? When a patient receives treatment that the plan doesn’t cover, the amount the patient pays doesn’t count toward the out-of-pocket limit (OOP). Also, plans may have co-payments, special deductibles, or other costs that don’t count toward the OOP. For example, a plan might limit mental health visits to 8 per year. The breast cancer example is based on more than 8 visits, so the costs of visits after the 8th one wouldn’t count toward OOP.

Version #2:

Examples

1. To help clarify further that these are not true patient costs, replace the headers

“Patient Pays” with “Patient Might Pay” in all three examples.

Q&A:

1. The HRA/FSA/HSA note doesn’t quite cover the point that contributions to

accounts help offset medical expenses. Suggest:

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Finally, consider other costs when you compare plans, such as your premium. and a Also, take into account employer contributions to medical accounts such as health savings accounts (HSAs), flexible spending accounts (FSAs), or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Your agent, broker, or employer can help you determine how these impact your overall costs.

By electronic mail

May 3, 2011

Jennifer Cook

Jane Sung

National Association of Insurance Commissioners

444 North Capitol Street, N.W.

Suite 701

Washington, D.C. 20001

Re: Public Comment -- Coverage Facts

Dear Ms. Cook and Ms. Sung:

America’s Health Insurance Plans is pleased to provide the NAIC’s Consumer Information (B)

Subgroup with the following comments on its work group’s April 29, 2011 draft coverage facts

documents. While we appreciate the considerable time and effort that has been expended in the

development of these documents, we also understand that are to be subjected to consumer focus

testing, thus the documents remain subject to continued refinements and quite possibly to

significant change.

AHIP is the national association representing approximately 1,300 health insurance plans that

provide coverage to more than 200 million Americans. Our members offer a broad range of

health insurance products in the commercial marketplace and have demonstrated a strong

commitment to participation in public programs as well. We appreciate the continuing efforts by

Superintendent Kofman (ME) and Administrator Miller (OR) to provide an inclusive process for

Statutory Members and interested parties in their work to develop coverage facts documents.

Recognizing that the documents are about to undergo consumer focus testing, during which

consumer groups will examine the language of the documents in some detail, we anticipate that

the specific document language will, if prior testing is any guide, significantly change. Thus, we

are limiting our comments to general observations, with a few exceptions.

AHIP members remain concerned that the coverage facts labels are too complex in

their design and will prove confusing to consumers.

While version 2 appears to present cost and reimbursement information in a simpler format than

version 1, both versions attempt to provide considerable facts and figures about specific medical

conditions within a larger document that is attempting to provide a general overview of insurance

May 3, 2011

Page 2

products. The level of information needed to address complex medical conditions puts in

question whether this additional information can be supported within the so-called 4 pager.

Earlier testing indicated a willingness by consumers to receive simplified information, provided

they were also given a source for more detailed information. We respectfully suggest that the

coverage forms be simplified, in conjunction with providing consumers with a source for

additional information.

While we recognize that the working group has endeavored to provide coverage facts

information in a manner that will reduce the possibility that consumers will look upon the

coverage facts label information as a source for estimating actual treatment costs, we remain

concerned that the detailed presentation of information within the coverage facts illustrations will

lead consumers to that conclusion. This is of particular concern where there is a wide variation

in treatment and costs for a particular condition, such as breast cancer. Simplification of the

materials will reduce this possibility.

Carrier testing is incomplete; the Subgroup must develop carrier instructions for

the completion of the forms and then review ability of carriers to complete the

forms.

While various versions of the forms have been reviewed by carriers to determine whether they

can complete the forms for various insurance products, this review, at best, has been cursory as

the forms have continually evolved. Perhaps more importantly, carriers have not been provided

any instructions or other guidance as to how the documents are to be completed. While carriers

have made a good faith effort to inform the Subgroup of their ability to use the forms, their

observations may change significantly with the creation of instructions.

If consumers are to use these coverage facts documents as a basis for product selection, it is

imperative that carriers complete the documents in as consistent a manner as possible. Carrier

instructions will be critical to this process.

The creation of carrier instructions for the so-called 4 pager forced the Subgroup to address a

number of operational issues, some of which had a significant impact on the form and on the

form and substance of the 4 pager. Based on this, it appears likely that the creation of carrier

instructions will have a similar impact on the coverage facts documents.

As part of the instructions process, HHS will need to create a process to keep coverage label

illustrations current as to procedures and costs to keep the illustrations relevant to consumers.

This process by its very nature will raise cost and implementation timeline issues for carriers.

Finally, with regard to carrier instructions, completion of instructions will enable carriers to

develop more precise cost estimates for implementation. Our members remain concerned with

May 3, 2011

Page 3

the possible significant operational costs of implementing both the coverage facts documents and

the larger so called 4 pager, and the ability to implement the requirements of HHS regulation

within 12 to 18 months, or longer, from a final effective date to accommodate information

systems development and business implementation timeframes.

Specific document language concerns

While we are awaiting consumer testing results before we submit detailed language comments,

we offer the following comments as they may assist the Subgroup in preparing its final drafts for

consumer testing.

“Total Costs” appears to be used for “allowed costs.” Will this cause members to

think there are no provider discounts from a plan? Consider “Amount owed to

providers for care” as a title.

In version 2, “insulin” is not specifically mentioned. We do not believe that insulin is

a prescription drug. The Subgroup may want to confirm this with a clinician and

clarify, if needed.

We would also recommend adding language to exclude any International Benefit

Plans from all standardized document requirements.

Thank you for the opportunity to comment upon the proposed drafts, and we look forward to

receiving final copies by this Friday, so that we can commence our consumer focus testing in

conjunction with BCBSA.

Please do not hesitate to contact me on my cell phone at (202) 378-8927 if we can provide

further information or assistance on this letter.

Sincerely,

Martin L. Mitchell, Jr.

Director, Product Policy

May 3, 2011 VIA ELECTRONIC MAIL Superintendent Mila Kofman, Co-Chair Administrator Teresa Miller, Co-Chair National Association of Insurance Commissioners (B) Committee Consumer Information Statutory Working Group National Association of Insurance Commissioners 701 Hall of the States 444 North Capitol Street, N.W. Washington, D.C. 20001-1509

RE: NAIC Consumer Information Working Group – Draft Coverage Facts Documents

Dear Superintendent Kofman and Administrator Miller: UnitedHealthcare is pleased to provide the National Association of Insurance Commissioners (“NAIC”) and the Consumer Information Statutory Working Group (“Working Group”) with our comments on the April 29, 2011 drafts of the Coverage Facts documents. We offer general comments based on the approach for the Coverage Facts label under consideration by the Working Group. This approach would require insurers to develop labels for a limited number of medical scenarios, with specific medical services and associated costs specified by the Health and Human Services Agency (“HHS”). The labels would be embedded in the Summary of Coverage document. The labels may be confusing to consumers by providing cost examples that will vary

significantly from their actual costs.

The labels will be produced based on information provided by HHS, including all medical services that HHS indicates should be delivered under their scenarios, associated costs and specific assumptions about the coverage scenario (e.g., accumulation toward deductible, network selection, drug selection). As a result, the coverage labels will not indicate differences in cost sharing due to variation in the insurer’s contracted rates with physicians and hospitals, cost differentials due to geographic variation, variation in policies used to reimburse providers and insurer programs to help consumers manage their medical condition and treatment. The labels also will not reflect costs specific to the consumer, including the actual services recommended by their physician, treatments for other medical conditions that may impact their cost sharing, and their selection of physicians, hospitals and other care providers.

The Working Group has acknowledged this issue by including disclaimer statements on the draft labels indicating that the cost sharing scenarios are illustrative only and should not be used to estimate treatment costs. We strongly recommend that these disclaimers remain prominently displayed on the coverage labels, in order to ensure that consumers understand the information presented and its limitations.

The labels should illustrate medical scenarios that present simple, less complex

treatments with minimal variation.

The coverage labels are intended to present consumers with examples of cost sharing for certain treatment scenarios, based on a specific plan’s coinsurance, copayments, deductibles, out-of-pocket maximums and other cost sharing. Presenting this type of information for complex medical scenarios may produce labels that are confusing to consumers, because there is typically much more variation in treatment for complex conditions. Using simpler medical scenarios may be more relevant to a greater number of consumers and may pose less risk in leading consumers to expect certain services to treat a condition. For example, breast cancer treatment may include different types of radiation, hormone therapy, chemotherapy and surgical procedures, depending on the type and the stage of the cancer. Beyond treating a patient’s breast cancer, there may be further complexity based on treatment for the stage and type of tumor, with different surgical procedures, chemotherapy, drugs and other options available. A chronic condition like diabetes may be similarly complex to illustrate, due to treatment for the metabolic condition and additional services needed for any diabetes complications (e.g., kidney, eye, foot conditions). We recommend using simple, less complex medical conditions that may be defined with limited variability. Alternatively, we recommend that any medical conditions illustrated use a normative scenario, with the list of services being limited to those that are most commonly used for treatment, according to recognized clinical resources.

The Working Group should consider further issues related to the development and

delivery of the labels.

While the labels will illustrate cost sharing for specific medical scenarios, extensive programming will be required to develop the actual cost sharing reflected in the documents. This programming will be based on the services and associated costs specified by the Agency, as well as numerous assumptions (e.g., network tier, drug tier, time period for delivery of services) necessary to develop the cost sharing example. We recommend that the Working Group develop guidelines for completing the labels, in order to ensure consistency among insurers. The Working Group should also consider additional complexities associated with development of the labels in the large group and self-funded market segments, where there is significant custom benefit design as well as the carve-out of select benefits (e.g., pharmacy, mental health, substance abuse) to other vendors. The benefit carve-outs raise questions about development of coverage labels that may require benefit information and programming by multiple insurers or plan administrators.

We also suggest that the Working Group consider recommendations on the distribution of the coverage labels. Providing access to the documents online or through electronic transmission – with paper copies available upon request – would be consistent with the manner in which

insurers and many other businesses distribute important consumer information. The Working Group may also consider other elements that could reduce distribution costs, including whether the labels can be produced in black/white rather than color.

We appreciate your consideration of our comments and look forward to continuing to work with the Working Group on these issues. Please do not hesitate to contact me at (714) 226-3466 if we can provide further information or assistance on this initiative. Sincerely yours,

Joy O. Higa Attachment cc: Jennifer Cook, NAIC Jane Sung, NAIC