Date post: | 08-Jan-2017 |
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© 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!!
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?