marketplace plans what to expect in 2017 and beyond

© 2016 Enroll America | StateOfEnrollment.org

05.12.16

Marketplace Plans: What to Expect in 2017 and Beyond


1. Get everyone up to speed on changes coming in 2017

Quality ratings Standardized plans

2. Review trends in marketplace plans

Session Objectives


Today’s Speakers

Paul Cotton Director of Federal Affairs, National Committee for Quality Assurance

Lydia Mitts Senior Policy Analyst, Families USA

Jason Bello Associate Partner, Center fro U.S. Health System Reform, McKinsey & Company

Molly Warren (moderator)

Senior Policy Analyst, Best Practices Institute, Enroll America


MARKETPLACE QUALITY MEASURES & REPORT CARDS

Paul Cotton, National Committee for Quality Assurance


• The National Committee for Quality Assurance• ACA Requirement for ‘Performance-Based

Marketplace Qualified Health Plan Accreditation

• Marketplace Quality Measures

• Marketplace Report Cards

• Your Feedback Needed & Wanted!

AGENDA

© 2016 Enroll America | StateOfEnrollment.org 6

NCQA: a non-profit that works to improve quality, cost & experience of care through:

• Measurement• Transparency• Accountability

America’s largest health plan accreditor• ACA mandated ‘performance-based’

accreditation reviews actual quality of care, patient protections & ‘experience of care’ plans have delivered

• NCQA Accredited plans cover 224M+ Americans, ~85% of Marketplace QHPs

National Committee for Quality Assurance


NCQA Health Plan Accreditation

Structure &

Process

50% of Score

Performance-Based Accreditation

CAHPS: Consumer Assessment of

Health Providers & Systems

50% of Score

HEDIS: Health Care Effectiveness

Data & Information Set


Quality Improvement• Managing, coordinating & improving care

Utilization Management• Coverage & appeals

Credentialing• Verifying provider qualifications

Member Rights & Responsibilities• Helping enrollees understand & use benefits

Member Connections• Self-care & patient services

Network Management• Adequacy, transparency, out-of-network requests

Structure & Process Standards


Marketplace QHPs must report measures on:• Clinical Quality, (31) including HEDIS:

• Diabetes Care• Cancer screenings• Blood Pressure Control• Prenatal & Postpartum Care• Use of Imaging for Low Back Pain (overuse)

• Enrollee Satisfaction Survey (ESS -12):• Care Coordination• Cultural Competence• Rating of Plan & Doctor• Access to Care & Information

Marketplace Quality Measures


Results Feed Quality Ratings System (QRS) • For 2017 open enrollment season this fall, plans

will be rated on a 5-Star scale• Similar to Medicare Advantage ratings @ medicare.gov

• CMS will pilot in Michigan, Ohio, Pennsylvania, Virginia, & Wisconsin

• State-based Marketplaces may choose to also display

• Not like YELP! Based on:• Objective, independently verified measures of the

clinical quality plans have delivered, & • Survey of random enrollee sample• Not subjective reviews by self-selected individuals

Marketplace Plan Report Cards


Medicare Health Plan Compare


Marketplaces bring quality ratings & report cards to new audiences of navigators, brokers, other assisters & consumers themselves

Your Feedback Needed & Wanted!

• Pilots are a significant opportunity to test what Marketplace consumers find helpful

• This can contribute to larger effort to make measures & ratings more helpful for making informed choices


Paul Cotton (202) 955 5162 – [email protected]


NEW PLANS AND TOOLS COMING TO HEALTHCARE.GOV IN 2017

Lydia Mitts, Families USA

FamiliesUSA.org

Who We Are and What We Do

Families USA is a national, non-profit, non-partisan consumer advocacy organization dedicated to the achievement of high-quality, affordable health care and improved health for all. In our work, we:

Advance health care policies that improve access, affordability, and quality of care

Research and produce timely reports and other resources on health care issues

Provide policy technical assistance to advocates at the state and community levels

FamiliesUSA.org

Roadmap

Overview of new provider network labels on healthcare.gov

Overview of new standardized plans on healthcare.gov

Key things to consider when comparing standardized plans

How will the healthcare.gov website feature standardized plans?

FamiliesUSA.org

All QHPs will have label to distinguish network breadth

Label is based on breadth of network for:

Primary Care Physicians Pediatric Primary Care

Physicians Hospitals

Label is only based on how QHP compares to other QHPs

New Network Breadth Ratings on Healthcare.gov

Basic

Standard

Broad

QHP Network Labels

FamiliesUSA.org

Standardized Plans in Federally Facilitated Marketplaces

Federal government designed Bronze, Silver, Silver CSR, and Gold metal level plans – called “standardized plans”

HHS has defined what cost-sharing must be for the majority (but not all) types of care in these standardized plans

Standardized plans will be available in federally-facilitated marketplaces in 2017 but…

Insurers are not required to sell these standardized plans

FamiliesUSA.org

Snapshot: Federal Standardized Silver Plan

Deductible $3,500 (Double for Family Plan)Annual Out-of-Pocket Limit $7,150 (Double for Family Plan)

Covered Pre-Deductible Cost-SharingPrimary Care Visits X $30 Specialty Care Visits X $65 Mental Health/SUD Visits X $30 Lab Services 20%X-Rays 20%Imaging 20%Rehab Speech/Physical Therapy 20%Urgent Care X $75Emergency Room Care $400Outpatient Facility Fee 20%Outpatient Surgery-Physician Fee 20%Inpatient Care 20%Generic Drugs X $15 Preferred Brand Drugs X $50 Non-Preferred Brand Drugs X $100 Specialty Drugs X 40%

FamiliesUSA.org

Benefits of Standardized Plans

1. Can compare multiple insurers’ standardized plans based on differences other than cost-sharing

2. Likely to have similar premiums to existing plans on the market

3. Standardized silver plan helps pay for many types of outpatient services before the deductible: Primary Care Specialty Care Mental Health/Substance Use Disorder Visits Urgent Care All Prescription Drugs

FamiliesUSA.org

What isn’t standard in the standardized plans?

Two insurers’ standardized plans could have different:

Premiums Provider networks Rx they cover, formulary tier for an Rx Additional covered benefits, eg. Dental Cost-sharing for services that HHS has not defined

HHS has not defined the cost-sharing in standardized plans for:

Durable Medical Equipment Habilitative Services Home Health Services Pediatric Dental/Vision

FamiliesUSA.org

How will the standardized plans look?

HHS plans to develop consumer-tested tools on healthcare.gov that help identify standardized plans

Website tools that consumer groups have discussed: Ability to filter plans, only show standardized plans Prompt at start of plan selection, explains standardized

plans/asks if you want to see these plans first Automatic plan sort shows standardized plans at top of the

plan options

What are your thoughts on how best to feature these plans on healthcare.gov

1201 New York Avenue, NW, Suite 1100Washington, DC 20005

main 202-628-3030 / fax 202-347-2417

Additional Families USA Resources: HHS Finalizes Health Insurance Plan Standards, Enrollment for 2017: http://

familiesusa.org/blog/2016/03/cms-finalizes-health-insurance-plan-standards-enrollment-2017

Non-Group Health Insurance: Many Insured Americans with High Out-of-Pocket Costs Forgo Needed Health Care: http://familiesusa.org/product/non-group-health-insurance-many-insured-americans-high-out-pocket-costs-forgo-needed-health

Designing Silver Plans with Affordable Out-of-Pocket Costs for Lower– and Moderate-Income Consumers: http://familiesusa.org/product/designing-silver-health-plans-affordable-out-pocket-costs-lower-and-moderate-income

Standardized Health Plans: Promoting Plans with Affordable Upfront Out-of-Pocket Costs: http://familiesusa.org/product/standardized-health-plans-promoting-plans-affordable-upfront-out-pocket-costs

Lydia MittsSenior Policy AnalystFamilies [email protected](202)628-3030

http://familiesusa.org/blog/2016/03/cms-finalizes-health-insurance-plan-standards-enrollment-2017



http://familiesusa.org/product/non-group-health-insurance-many-insured-americans-high-out-pocket-costs-forgo-needed-health



http://familiesusa.org/product/designing-silver-health-plans-affordable-out-pocket-costs-lower-and-moderate-income

http://familiesusa.org/product/designing-silver-health-plans-affordable-out-pocket-costs-lower-and-moderate-income

http://familiesusa.org/product/standardized-health-plans-promoting-plans-affordable-upfront-out-pocket-costs



mailto:[email protected]


EXCHANGES: LESSONS LEARNED THREE YEARS IN

Jason Bello, Center For U.S. Health System Reform, McKinsey & Company

25healthcare.mckinsey.com | Center for US Health System Reform

Disclaimer: McKinsey is not an investment adviser, and thus McKinsey cannot and does not provide investment advice. Opinions and information contained in this material constitute our judgment as of April 15, 2014 and are subject to change without notice. They do not take into account your individual circumstances, objectives, or needs.

Nothing herein is intended to serve as investment advice, or a recommendation of any particular transaction or investment. Nothing herein is intended to serve as investment advice, or a recommendation of any particular transaction or investment, any type of transaction or investment, the merits of purchasing or selling securities, or an invitation or inducement to engage in investment activity. While this material is based on sources believed to be reliable, McKinsey does not warrant its completeness or accuracy.


In 2016 OEP, what offerings were available to consumers, and how has

this evolved since 2014?


In 2016, close to two-thirds of consumers saw a carrier exit their market, while nearly half had a new carrier choice on exchange

2014 carriers 2015 withdrawals 2015 new entrants 2015 carriers 2016 withdrawals 2016 new entrants 2016 carriers

282

19

70

333

49 31

315

63%of consumers sawan exit by a carrier

47% of consumers saw a new entrant on the exchange


Many consumers saw new price leaders in 2016 and may have had to switch carriers to get the lowest-price option% of QHP-eligible consumers seeing given carrier type offering lowest-price silver plan in their county

201620152014

26 24

45

10

17

10

18

1013

18

2420

25

15

Blue Regional/local Provider National CO-OPMedicaid

12

28

3

58%of consumers saw a new silver-tier price leader in 2016


Consumers also saw more managed, narrow network plans on exchanges…

2014 2015 2016

38 3730

4 44

33 3340

25 26 26

% of competitively priced (<10% lowest-price) silver plan offerings by plan type across years

% of competitively priced silver plan offerings in rating areas with at least one narrowed network by network breadth across years1

PPO

POS

HMO

EPO

2014 2015 2016

8 8 8

5035

27

7

1014

3547 51

Tiered

Broad

Ultra-narrow

Narrow

1 Broad: more than 70% of hospitals participating in a rating area; Narrow: more than 30% and less than or equal to 70% of hospitals participating; Ultra-narrow: less than or equal to 30% of hospitals participating; Tiered: any network with multiple levels of in-network cost-sharing.


…with fewer network choices overall% of QHP-eligible consumers with access to various network types1

Narrowed only

Both

Broad only

8

83

9

2014

5

86

9

2015

14

74

12

2016

1 Broad: more than 70% of hospitals participating in a rating area; Narrow: more than 30% and less than or equal to 70% of hospitals participating; Ultra-narrow: less than or equal to 30% of hospitals participating; Tiered: any network with multiple levels of in-network cost-sharing. Narrowed networks comprise Ultra-narrow, Narrow and tiered networks.


Even broad networks have become more managed

% of silver network offerings by plan type and network breadth1,2,3

2014 2015 2016 2014 2015 2016 2014 2015 2016

8 5 9 7 6 5 8 10 6

48 5235

30 2620

25 1615

17 15

19

1210

1512

1411

26 2837

52 59 60 56 6069

Broad Narrow Ultra-narrow

1,148 1,548 1,295 507 623 612 443 479 451

EPO

PPO

POS

HMO

1 Plan types reported were taken directly from exchange websites and Summary of Benefits and Coverage (SBC) documents.

2 When multiple silver plans are available on a single network we use the plan type associated with the lowest-price silver plan in that network.

3 Broad: more than 70% of hospitals participating in a rating area; Narrow: more than 30% and less than or equal to 70% of hospitals participating; Ultra-narrow: less than or equal to 30% of hospitals participating; Tiered: any network with multiple levels of in-network cost-sharing.


The shift toward managed and narrower varies by market for consumers

–15% or less

–15% to 0%

0% to 15%

KEY:-100%

-50% to -25%

KEY:

-75% to -50%

-99% to -75%

-25% to 0%

No PPOs in 2015 and 2016

75%+

25% to 50%

50% to 75%

0% to 25%

% change in number of PPO offerings by county from 2015 to 2016

% change in broad hospital networks by county from 2015 to 20161

15% to 30%

30% to 45%

45% to 100%

Not available2

1 Broad networks have more than 70% of hospitals participating in a rating area2 Network breadth unavailable due to lack of hospitals in the rating area


Many consumers are seeing lower premiums, as managed and narrowed network plans continue to have lower rate increases…Median silver premium increases among re-filed 2014 and 2015 plans

By re-filed plan type

%

By network type1

%

10

12

BroadNarrowed1

2015-16

1 Broad: more than 70% of hospitals participating in a rating area; Narrow: more than 30% and less than or equal to 70% of hospitals participating; Ultra-narrow: less than or equal to 30% of hospitals participating; Tiered: any network with multiple levels of in-network cost-sharing. Narrowed networks comprise Ultra-narrow, Narrow and tiered networks.

8

16

PPOHMO


… and the premium difference between narrowed and broad continues to widen

2016

2015

2014

% difference between median premium for broad and narrowed networks from the same carrier and plan type1,2,3

BRONZE

+11

+15

+17

SILVER

+16

+16

+22

GOLD

+16

+16

+23

PLATINUM

+17

+23

+33

1 Broad: more than 70% of hospitals participating in a rating area; Narrowed: includes networks with multiple tiers or non-tiered networks with less than or equal to 70% of hospitals participating. Narrowed networks for this analysis include narrow and ultra-narrow networks but do not include tiered networks.

2 Plan types include PPO, HMO, EPO, and POS2 Median prices are based on premiums for a 40–year-old single non-smoker. When a network has multiple

plans, the lowest-price plan is used as price of the network. If there are multiple networks available for selection as “narrowed,” the narrowest is selected. If there are multiple networks available for selection as broad, the broadest is selected.


Across these offering trends, what has payors’ performance been to date?


Most states saw negative margins across their individual line of business

State-level post-3R post-tax 2014 margin across individual line of business Percent

▪ States varied widely in their margins: 9 states reported positive aggregate margins, 41 states and DC reported negative margins

▪ The three states with the most positive margins include WA (+8% margin), CA (+6%) and VT (+5%)

▪ The states with the most negative margins are MT (-21%), NE (-23%) and UT (-28%)

SOURCE: McKisney Payor financial database; McKinsey Center for US Health System Reform

Nationwide, the individual market lost $2.7B in 2014, with only ~30% of payors having positive margins


Exchange carriers with narrower networks had better margins and lower claims, in aggregate, than those offering broad networks

2014 post-3R, post-tax individual market financial metrics across exchange carriers1

Weighted average by QHP membership

Weighted-average network breadth2,3

Post-3R post-tax margin, %

Risk adjustment, % of premiums4

Reinsurance, % of premiums

Risk corridors, % of premiums5 Claims PMPM, $

Ultra-narrow

Narrow

Broad -8

-7

-2

0

-3

-6

18

17

13

0.5

0

346

307

301-0.6

0.5

1 Carrier performance was determined at the NAIC/HIOS state-level entity level. Analysis only includes entities HIOS ID’s associated with on-exchange plans in 2014, with >1K 2014 QHP members.2 In this analysis, tiered networks are assigned to the ultra-narrow, narrow, or broad category based on the breadth of the first tier.3 Network breadth for each entity is rolled-up to a state-level (from county) using QHP-eligible population and the network associated with the lowest-price silver plan. Each state-level entity is then associated with

their respective breadth category (broad, narrow, ultra-narrow). The financial metrics for all entities in each breadth category are weighted by their 2014 QHP lives, obtained from CMS MLR reports.4 Risk adjustment does not total to 0 as data reflects only those entities with on-exchange presence in 2014. Negative values indicate payment into the program. In aggregate, risk adjustment for all exchange entities

amounted to –1% of premiums.5 Net risk corridor payments across these carriers amount to -$17M.


Thank YouFor more information,

please go to healthcare.mckinsey.com/reformor email [email protected]


QUESTIONS?