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

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 – cotton@ncqa.org

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-Sharing
Primary 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 $75
Emergency Room Care $400
Outpatient 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 1100
Washington, 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 Mitts
Senior Policy Analyst
Families USA
lmitts@familiesusa.org
(202)628-3030

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
282
19
70
333
49
31
315
2014 carriers 2015 withdrawals 2015 new entrants 2015 carriers 2016 withdrawals 2016 new entrants 2016 carriers
63%
of consumers saw
an 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
10
13
18
24
20
2
5
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…
38 37
30
4 4
4
33 33
40
25 26 26
2014 2015 2016
% 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
8 8 8
50
35
27
7
10
14
35
47 51
2014 2015 2016
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
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
8 5 9 7 6 5 8 10 6
48 52
35
30 26
20
25 16
15
17 15
19
12
10
15
12
14
11
26 28
37
52
59 60 56 60
69
2014 2015 2016 2014 2015 2016 2014 2015 2016
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 area
2 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
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 POS
2 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 You
For more information,
please go to healthcare.mckinsey.com/reform
or email Jason_Bello@mckinsey.com

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