Let's Go Shopping: Helping Consumers Navigate Plan Selection

© 2016 Enroll America | StateOfEnrollment.org

05.13.16

Let's Go Shopping: Helping Consumers Navigate Plan Selection

© 2016 Enroll America | StateOfEnrollment.org

Today we will learn:1. Tips and tricks on how to explain certain

health insurance concepts to non-experts2. How certain plan design features can impact

cost and where to look to find important plan information

3. How tools can help make an in-person assistance appointment more effective and efficient

Session Goals

© 2016 Enroll America | StateOfEnrollment.org

Today’s Speakers

Adam Fox Director of Strategic Engagement, Colorado Consumer Health Initiative

Dave Chandrasekaran

Health Care Consultant & Certified Application Counselor

Jennifer Sclar Chief Executive Officer,Clear Health Analytics

Sophie Stern (moderator)

Deputy Director, Best Practices Institute,Enroll America

© 2016 Enroll America | StateOfEnrollment.org

The Uninsured are Price Sensitive

I can't afford health insurance

Purchasing a plan on my own does not seem worth it financially

I expect to have insurance soon through a job or through a spouse's job

I can get the care I need without health insurance

Getting insurance is not something I really think about

61%

9%

9%

6%

6%

59% of those that said they cannot afford had not heard of financial help

© 2016 Enroll America | StateOfEnrollment.org

Premium

Out-of-

pock

et co

sts

Deduc

tible

Copay

ments

Benefi

ts co

vered

Penalt

y/fine

ER costs

Tax cr

edit

Doctor

s in n

etwork

59%

47%43% 41% 39%

30% 29%

22%19%

Thinking about the last time you looked for health insurance on your own, which of the following things did you consider before deciding NOT to purchase a plan?

Source: GMMB and PerryUndem Research and Communication, May 2015, https://s3.amazonaws.com/assets.enrollamerica.org/wp-content/uploads/2014/10/Reaching_Consumers_in_OE3.pdf

The Uninsured are Paying Attention to Premiums and Deductibles

© 2016 Enroll America | StateOfEnrollment.org

Marketplace Enrollees Also Considered Cost Sharing

Premium

Out-of-

pock

et co

sts

Benefi

ts

Deduc

tible

Co-pay

ments

Drs in

netw

ork

Tax cr

edit

ER costs

Penalt

y/fine

73%

57% 57% 56%52%

42%36% 35%

26%

Thinking back to when you were deciding whether to purchase a plan, which of the following things did you consider?

Source: GMMB and PerryUndem Research and Communication, May 2015, https://s3.amazonaws.com/assets.enrollamerica.org/wp-content/uploads/2014/10/Reaching_Consumers_in_OE3.pdf

© 2016 Enroll America | StateOfEnrollment.org

CHOOSING A PLAN STARTS WITH HEALTH INSURANCE LITERACY

Adam Fox, Director of Strategic Engagement, Colorado Consumer Health Initiative

Outline

• Making health insurance literacy more accessible– CCHI’s work - CoveredU.org digital tool

• Health insurance – Fun with analogies

• Keys to understanding Health Insurance– Learnings from CCHI’s work & consumer testing

Health Insurance Literacy: Explaining Copays, Coinsurance, Deductibles, and more!!

CoveredU.org (en Español – SeguroTU.org)cohealth.co/covereduinfograph

Major Goals:• Interactive content - gamelike• Contextualize terms/concepts• Make it less intimidating & don’t try to explain everything

at once• Demonstrate Value of Insurance• Emphasize importance of utilizing primary care• Go-to resource for individual consumers and health

enrollment assisters

+

• Keys to adult learning = contextualization, relatable examples, interactivity, and application.

Interesting ways to describe HI

Auto Repair

$$?

Interesting ways to describe HI terms

Premium

Interesting ways to describe HI terms

Copay

Interesting ways to describe HI terms

Deductible and coinsurance

Interesting ways to describe HI terms

In-Network vs. Out-of-Network

Keys to understanding HI

• Keep it Simple – both in language and complexity

• Try to keep it engaging and relevant (try to use examples you think will resonate with a person)

• Comparisons can help provide context

Shameless plug – check out our enrollment rap videos online cohealth.co/rapSEPs & cohealth.co/enrollmentrap

© 2016 Enroll America | StateOfEnrollment.org

TIPS AND TRENDS IN PLAN SELECTION

Dave Chandrasekaran, Health Care Consultant & Certified Application Counselor

1. Premium2. Plan Design/Cost Sharing3. Covered Benefits/Drug Formulary4. Provider Network

Elements of Marketplace Health Plans

19

1.2. Plan Design/Cost Sharing

• Deductible• Out-of-Pocket Maximum• Copays and Coinsurance

Elements of Marketplace Health Plans

20

Total Annual Medical Expenses

Insurer pays

Insurer pays

Consumer pays Consumer pays full amount of medical bills

Consumer pays Co-pays/Coinsurance

Consumer does not pay anything

Annual Deductible:

Annual Out-of-Pocket Maximum:Co

nsum

er P

ays

$2000

$6000

$2000

$4000

$0

21

Explaining Deductibles and Out-of-Pocket Max

22

deductible applies

HealthCare.gov, Anthem Blue Cross and Blue Shield Silver Blue Priority X WI 4000 25 plan in Green Bay, WI

Copays/Services Exempt from the Deductible

23

deductible does not

apply

Copays/Services Exempt from the Deductible

HealthCare.gov, Anthem Blue Cross and Blue Shield Silver Blue Priority X WI 4000 25 plan in Green Bay, WI

24

Terms used by health plans:• Exempt from the deductible• Deductible does not apply• Deductible is waived• Before the deductible

Copays/Services Exempt from the Deductible

HealthCare.gov, Anthem Blue Cross and Blue Shield Silver Blue Priority X WI 4000 25 plan in Green Bay, WI

25

Partial Exemptions from the Deductible

Summary of Benefits and Coverage for Anthem Healthkeepers Bronze X 4650 35 plan in Fairfax County, VA

26

Partial Exemptions from the Deductible

Healthcare.gov, Anthem Healthkeepers Bronze X 4650 35 plan in Fairfax County, VA

27

Partial Exemptions from the Deductible

Healthcare.gov, Anthem Healthkeepers Bronze X 4650 35 plan in Fairfax County, VA

28HealthCare.gov, Kaiser Permanente Bronze 4500/50/HSA/Dental/Ped Dental and Bronze 4500/50/Dental/Ped Dental plans in Fairfax County VA (2014)

HSA vs. non-HSA Plans

Deductible-only Plans

Healthcare.gov, Humana Bronze 6450/Detroit HMOx plan in Wayne County, MI

1. Premium2. Plan Design/Cost Sharing3. Covered Benefits/Drug Formulary4. Provider Network

Elements of Marketplace Health Plans

30

31

Essential Health Benefits

32

Dental Coverage for Children and Adults

Healthcare.gov, Coventry Bronze Deductible Only HSA Eligible Bon Secours plan in Richmond, VA, and Kaiser Permanente KP VA Bronze 6000/20%/HSA/Dental/Ped Dental plans in Arlington County, VA

33

Other Covered Services

Summary of Benefits and Coverage for Kaiser Permanente KP VA Bronze 6000/20%/HSA/Dental/PedDental in Arlington County, VA

34

CareFirst BCBS Innovation Health

Kaiser Permanente

United Healthcare

AbortionsAcupunctureBariatric surgeryChiropractic careDental care (adult)Infertility treatmentHearing aidsLong-term care

Private duty nursingRoutine eye exam (adult)Routine hearing tests (adult)Routine foot care

Other Covered Services

Summary of Benefits and Coverage for CareFirst BlueCross Blue Shield, Innovation Health, Kaiser Permanente and UnitedHealthcare plans in Arlington County, VA

1. Premium2. Plan Design/Cost Sharing3. Covered Benefits/Drug Formulary4. Provider Network

Elements of Marketplace Health Plans

35

36

Type Name PCP Required?

Referrals Required?

Out-of-Network

Coverage?

PPO Preferred Provider Organization No No Yes

POS Point of Service Yes Maybe Yes

HMO Health Maintenance Organization Yes Yes No*

EPO Exclusive Provider Organization No No No**except for emergency care

Health Plan Network Types

Health Plan Provider Networks

Health Plan Provider Networks

Primary Care Providers Hospitals

Orange Health Plan PPO

Health Plan Provider Networks

Primary Care Providers Hospitals

Red Health Plan HMO

v

Health Plan Provider Networks

Primary Care Providers Hospitals

Green Health Plan Integrated HMO

41

Specialty CareFirst BCBS

Innovation Health

Kaiser Permanente

United Healthcare

PCP/Internal Medicine (in 10 miles)

500 743 (15 miles)

79 402

Cardiologist (in 10 miles)

377 437 (15 miles)

4 124

Hospitals(in 10 miles)

20 3 (15 miles)

? 3

Health Plan Provider Networks

Provider search sites for CareFirst BlueCross BlueShield, Innovation Health, Kaiser Permanente, and UnitedHealthcare for Arlington County, VA

42

Tiered Provider Networks

Plan Brochure for Independence Blue Cross HMO Silver Proactive Plan in Philadelphia County, PA

43Summary of Benefits and Coverage for Independence Blue Cross HMO Silver Proactive Plan in Philadelphia County, PA

Tiered Provider Networks

44Source: healthcare.gov

Gray

Healthcare.gov Provider Search Tool

45Source: healthcare.gov

Healthcare.gov Provider Search Tool

46

Healthcare.gov Out-of-Pocket Cost Calculator

47Source: healthcare.gov

Healthcare.gov Out-of-Pocket Cost Calculator

48

Finding Plans that Meet the Consumers’ Needs

Applicants (age): Pamela (43) and Stephanie (16)

Location: Detroit, MICounty (Zip): Wayne (48201)

Annual Income: $35,000APTC: $145CSR?: Yes (73%)

Doctors for Pamela? YES – Susan Berman MD (OB/GYN)Doctors for Stephanie? NO

Prescription Drugs for Pamela? YES – Metformin 500mg XRPrescription Drugs for Stephanie? NO

Hospital? YES – St John Macomb Oakland Hospital

49

Finding Plans that Meet the Consumers’ Needs

50

Finding Plans that Meet the Consumers’ Needs

51

Company Price Doc Rx Hosp Deductible OOP Max PCP Specialist Generic

1 Humana Bronze 6450/Detroit HMOx (HSA) $133 $12,900 $12,900 $0 after $0 after $0 after

2 Molina Marketplace Bronze $145 $10,000 $13,700 $25 after $75 after $15

3 BC Network of MI Metro Detroit HMO Bronze Saver (HSA) $148 $12,900 $12,900 $0 after $0 after $0 after

4 BC Network of MI Metro Detroit HMO Bronze (HSA) $158 $11,900 $12,700 $30 after $50 after $4 after

5 HAP Personal Alliance 5000 (HSA) $163 $10,000 $12,900 20% after 20% after 20% after

6 Harbor Health Plan Choice Bronze $164 $12,300 $13,700 $30 $55 $25

7 BC Network of MI Select Bronze Saver(HSA) $177 $12,900 $12,900 $0 after $0 after $0 after

8 Humana Silver 3800/Detroit HMOx $182 $6,500 $9,500 $20 $40 $16

9 BCBS of MI Select Bronze (HSA) $188 $11,900 $12,700 $30 after $50 after $4 after

10 HAP Personal Alliance 6850 HMO $206 $13,700 $13,700 $0 after $0 after $0 after

11 Harbor Health Plan Choice Silver $207 $4,600 $10,900 $5 $10 $10

19 BC Network of MI Metro Detroit HMO Silver Saver $223 $3,600 $10,000 $30 $50 after $4 after

Finding Plans that Meet the Consumers’ Needs

Source: heathcare.gov, plans for a family of two (43 and 16 years old, $35,000/year) in Wayne County, MI

PREMIUM• Target premium range (upper limit)?

PLAN DESIGN• Balancing monthly cost vs. deductible amount• First dollar coverage (for primary care/generic drugs)?• Frequently used services (which copays are most important)?• Health status/healthcare needs (to estimate annual OOP costs)?

BENEFITS/PRESCRIPTION DRUGS• Dental coverage included (for kids? for adults?)• Need for “Other Covered Services”?• Coverage of current prescription drugs?

PROVIDER NETWORK• Current doctor in network?• Size of provider network (out-of-network coverage?) 52

Helping Consumers Identify their Priorities

© 2016 Enroll America | StateOfEnrollment.org

ONE SIZE DOES NOT FIT ALL: HELPING CONSUMERS CHOOSE

Jennifer Sclar, CEO, Clear Health Analytics

05/02/2023 54

Overview

The importance of decision support tools – helping consumers find the best plan to fit their needs

Overview of available tools and how they work

Deep-dive into the Plan Explorer

ClearHealthAnalytics - Confidential

05/02/2023 55

All Plans Are Not Created Equal Individual variables include likely utilization, income,

availability of subsidies and/or CSR, network and formulary

The best plan for an individual or family will vary depending on some combination of these

Manual calculation of out-of-pocket cost is impossible because of lack of pricing information, variation in plan design, and tedious math

Selecting the wrong plan can have significant impact on financial and physical well-being of consumers

ClearHealthAnalytics - Confidential

05/02/2023 56

Digital Tools Are Essential Digital tools allow consumers or those assisting

consumers to see how each plan will behave and what it will “really” cost

Tools allow doctor and formulary look-up

Many new tools are available including HC.Gov, Consumers Checkbook and Stride Health

Tools replace intuition and anecdote with unbiased, data-driven analysis

ClearHealthAnalytics - Confidential

Married Couple: 43 year-old

male, controlled diabetes

40 year-old female, no known conditions

Income: $59,000/year

Here’s How it Works

05/02/2023 ClearHealthAnalytics – Proprietary & Confidential 57

Tell us about your health….

Utilization Drives Total Cost

05/02/2023 ClearHealthAnalytics – Proprietary & Confidential 58

Medical Services They are Likely to Use:

Total Cost Drives Plan Selection

05/02/2023 ClearHealthAnalytics – Proprietary & Confidential 59

Top plans if utilization is edited to reflect 50 mental health visits/year.

Top plans if the suggested utilization is used to determine total cost.

Total Cost Drives Plan Selection

05/02/2023 ClearHealthAnalytics – Proprietary & Confidential 60

Top plans if the female is pregnant and income is $35,000/year

Top plans if the female is pregnant

05/02/2023 61

Tools Will Not Replace Humans

Plan selection is highly individualized, idiosyncratic, and anxiety-provoking

Many will continue to rely on navigators, assisters and brokers

Decision support tools can help navigators, assisters and brokers by saving time, and reducing variability and subjectivity in recommendations

ClearHealthAnalytics - Confidential

© 2016 Enroll America | StateOfEnrollment.org

QUESTIONS?