Families USA Vermont s Health Care Exchange Plan Design

Families USA: Vermont’s Health Care Exchange Plan Design Georgia J. Maheras, Esq. Project Director Vermont Health Care Innovation Project January 24, 2014 VERMONT HEALTH REFORM 3/15/2018 1

FIRST, A LITTLE BACKGROUND VERMONT HEALTH REFORM 3/15/2018 2

Some Features of Vermont’s Health System 14 community hospitals, including 8 critical access hospitals (fewer than 25 beds) 1 in-state academic medical center, plus Dartmouth. Hitchcock, provide most tertiary care 11 FQHCs serving more than 150, 000 Vermonters Fewer than 2000 physicians, more than half of whom are employed 3 health insurance carriers, only 2 in small group market 6. 8% uninsured VERMONT HEALTH REFORM 3/15/2018 3

Vermont’s Health Reform Goals* Assure that all Vermonters have Access to and Coverage for High Quality Care Improve the Health of Vermonters Reduce Health Care Costs and Cost Growth Assure Greater Fairness and Equity in How We Pay for Health Care *from the State’s Strategic Plan for Health Reform, February, 2012 VERMONT HEALTH REFORM 4

Who does what in Vermont health reform (2012 -14)? Department of VT Health Access: Exchange Expansion of Advanced Primary Care Practice Model Green Mountain Care Board: Cost Containment Payment reform Governor’s Office: Single payer financing and operations VERMONT HEALTH REFORM 5

Vermont Health Reform Timeline 2012 Control costs, pay for value Design a simpler system of coverage and financing 2014 Operate Vermont Health Benefit Exchange: single portal for insurance for non-group, small group and public programs After ACA waiver is available (2017? ) Green Mountain Care – unified system One payer for most Vermonters Public financing VERMONT HEALTH REFORM 6

VERMONT’S EXCHANGE REFLECTS VERMONT’S HEALTH CARE SYSTEM VERMONT HEALTH REFORM 3/15/2018 7

Features of Vermont’s Exchange • Vermont is an ACTIVE purchaser. • All plans offered to individuals and small businesses in 2014 will have been selected by Vermont Health Connect • Small Business can enroll directly with carriers for 2014 • Define small group at 50 full-time employees or fewer (2014 -2015) • Individual and small group markets merged VERMONT HEALTH REFORM 8

Vermont’s Process Vermont’s Exchange Team developed standardized plans. – Listening sessions – Actuarial support – Current market scan Vermont’s Agency of Administration proposed plans to the Green Mountain Care Board for approval. Green Mountain Care Board held a series of public meetings and solicited public comment. VERMONT HEALTH REFORM 3/15/2018 9

Administration’s Principles for Decision Making Creating meaningful choice for consumers Encouraging high value services, like primary care and generic drugs, and innovation – in alignment with State priorities Minimizing disruption for small group and individual market Maximizing portability of plans, allowing consumers to move between employer and individual coverage while maintaining desired plan Affordability Administrative simplicity Maximizing individual premium tax credits VERMONT HEALTH REFORM 1

Administration Stakeholder Input Workgroup with a variety perspectives met over last few months – Included consumer and patient advocates, brokers, representatives from insurance companies, providers, and other interested parties – Weighed in on number of plans to offer on the Exchange and the cost-sharing structures they prefer – Examples of input: priority to low copays for PCP office visits and generic drugs, certain services before deductible, include coinsurance to encourage consumer cost awareness, align cost-sharing within tiers and by services, offer fewer and distinct plans, allow insurance companies flexibility VERMONT HEALTH REFORM 1

Approach Recommendations A hybrid approach of state-specified plan designs and some “choice” plans designed by insurance carriers within set parameters 4 specified design options across four actuarial levels: – At Platinum: 1 Specified Plan Design – At Gold: 1 Specified Plan Design – At Silver: 2 Specified Plan Designs – At Bronze: 2 Specified Plan Designs Additional “Choice” Plan Designs VERMONT HEALTH REFORM 12

“Choice” Plan Design The Green Mountain Care Board granted DVHA authority to approve “Choice” plans Process: – State released RFR – Insurers submitted qualified “choice” plan designs – DFR reviewed submissions and certified plans – DVHA selected plans to offer on the Exchange from certified plans based on specific criteria VERMONT HEALTH REFORM 1

“Choice” Plan Design Criteria DVHA would used the following criteria in choosing a “Choice” plan: Meaningfully different from standard plans – Distinct design structure within same AV level, e. g. , difference of $500 in deductible, or an AV that varies by at least 10% for three major service categories – Ensures additional plan designs offered will increase the diversity of options for groups/members – Both quantitative and non-quantitative differences Fosters significant innovations in: – Wellness promotion - demonstrated experience and success – Promoting individual engagement in prevention VERMONT HEALTH REFORM 1

Platinum 1 Specified Design 0 Choice Design Gold Proposed Specified Plan Design Options 1 Specified Design 1 Choice Design Total Specified Design 6 Specified Designs 3 Choice Designs (to be discussed 9/6) Key: Circle = State-Specified Design Choice Design Silver 2 Specified Designs 1 Choice Design Bronze Square = Insurer Choice Design 2 Specified Designs 1 Choice Design Specified Design 1 Specified Design 2 Choice Design VERMONT HEALTH REFORM 15

Specified Silver Plans Deductible/Out of Pocket Maximum Medical Deductible (Individual/Family) Rx Deductible Integrated Deductible Medical Out of Pocket Maximum (Individual/Family) Rx Out of Pocket Maximum (Individual/Family) Integrated Out of Pocket Maximum Family Deductible/Out of Pocket Maximum Medical Deductible 1 waived for: Drug Deductible waived for: Service Category Hospital Services 2 Emergency Room 3 Preventive Silver Ambulance Rx Drug Coverage Rx Generic Rx Preferred Brand Rx Non-Preferred Brand Silver $1550/$3100 $100/$200 No $250 $0 20% 0% 10% $40 $60 20% • Priority for affordable cost $5100/$10, 300 $5750/$11, 500 - sharing for primary care & $1250/$2500 generic drugs No Rx -No, Medical - Yes • Variation in cost-sharing Stacked, 2 x Aggregate, 2 x Individual design between two plans Individual (mostly co- pays versus Prev, OV, UC, Preventive Amb mostly coinsurance) Generic scripts Wellness scripts • HDHP plan design qualifies for Copay / Coinsurance health savings accounts & Coinsurance 40% 20% health reimbursement accounts Why these 2 plans? $1250/$2500 Yes $20 $1900/$3800 Office visit w/PCP or Mental Health Specialist Office Visit 4 Urgent Care $100 $12 $50 50% 20% $10 $40 50% VERMONT HEALTH REFORM 16

Vermont Premium Reductions $300 Vermont’s health care programs had premiums that were more affordable than the ACA’s APTC. $250 Premium per Month $200 Vermont received Medicaid match to reduce the applicable percentage for premium payments by 1. 5% $150 $100 $50 $0 100% ACA Premium 150% 200% 250% Current Catamount and VHAP premium FPL Vermont Premium Reduction through Vermont Health Connect 300% VERMONT HEALTH REFORM 17

Vermont Cost Sharing Reductions VERMONT HEALTH REFORM 3/15/2018 18

Vermont Cost Sharing Reductions VERMONT HEALTH REFORM 3/15/2018 19