Health Plan Market & Benefit Comparison Part I

1. Health Plan Market & Benefit Comparison Part I Presented by Cliff Craig Health Plan Account Manager for Connect for Health Colorado

2. Key Topics to be Discussed • Review Basic Insurance Terminology • Key Things to Consider When Distinguishing Between Carriers & Benefit Coverage • Understanding Plan Benefits & Summary of Benefits and Coverage (SBC)

3. Review Basic Insurance Terminology

4. Simple Terms And Definitions • Monthly Premium – The monthly amount that you must pay for your health / dental insurance (coverage) • Annual Deductible - You need to pay this amount before your plans starts helping you pay for most covered services through coinsurance. You may have to cover some costs that will not count toward this total deductible. • Annual Out of Pocket Limit - This is the most you’ll pay for care during a policy period (usually a year) before your plan starts paying 100 percent for most covered services. • Copay - A fixed amount (for example, $15) you pay for a medical visit or for medication that is covered under your health plan, usually when you receive the service. This is considered part of your out-of-pocket costs, separate from premiums and deductibles. • Coinsurance - After reaching your deductible, you may start paying a percentage of the total cost for certain services. Coinsurance usually reflects the percentage of medical expenses that you are responsible to cover, for dental expenses the percentage reflects what the dental plan will cover.

5. Simple Terms And Definitions • In Network (Tier 1) –Whatyou pay for covered health care services to providers who are contracted with your health insurance or plan. In-network benefits cost you less than out-of-network benefits. • Out of Network – The benefits levels you pay for covered health care services to providers who are NOT contracted with your health insurance or plan. Out of network benefits cost are much higher than In-network benefits. • Summary of Benefits and Coverage (SBC) – This document will help consumers better understand the coverage they have and, for the first time, allow them to easily compare different coverage options. It will summarize the key features of the plan or coverage, such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions. People will receive the summary when shopping for coverage, enrolling in coverage, at each new plan year, and within seven business days of requesting a copy from their health insurance issuer or group health plan.

6. Annual Deductible • You need to pay this amount before your plan starts helping you pay for most covered services through coinsurance. • Most plans Copays do not apply and are not dependent on the Deductible. • Family Deductibles are normally 2 times the Individual Deductibles. • Deductibles accumulate on a calendar year, Jan. 1st to Dec. 31st. • Deductibles could or could not apply to the Out-of-Pocket Limit. • Once Copays, Coinsurance, Deductible & Out-of-Pocket Limit reach the Maximum Out-of-Pocket limit $6,350 individual / $12,700 family for a calendar year the Plan pays 100% Sample from a SBC document:

7. Annual Out of Pocket Limit • This is the most you’ll pay for care during a policy period (usually a year) before your plan starts paying 100 percent for most covered services. • Family Out-of-Pocket Limits are normally 2 times the Individual Out-of-Pocket Limits. • Out-of-Pocket Limits accumulate on a calendar year, Jan. 1st to Dec. 31st. • In the sample below the plan would pay 100% for coinsurance after the $5,200 / $10,400, the member will still pay for copays up to the $6,350 / $12,700 limit • Remember once Copays, Coinsurance, Deductible & Out-of-Pocket Limit reach the Maximum Out-of-Pocket limit $6,350 individual / $12,700 family for a calendar year the Plan pays 100% • Rx copays & deductibles are included in the Maximum Out-of-Pocket • Maximum Out-of-Pocket Limit applies to In-Network services ONLY Sample from a SBC document:

8. Copay & Coinsurance Copay A fixed amount (for example, $15) you pay for a medical visit or for medication that is covered under your health plan, usually when you receive the service. This is considered part of your out-of-pocket costs, separate from premiums and deductibles. • There may be separate copays for different services: Primary care, Specialist, Preventive care, Hospitalization, Emergency Room etc… • Some plans require that a deductible first be met for some specific services before a copayment applies Coinsurance After reaching your deductible, you may start paying a percentage of the total cost for certain services. Coinsurance usually reflects the percentage of medical expenses that you are responsible to cover, for dental expenses the percentage reflects what the dental plan will cover.

9. Allowed Amount & Balance Billing Allowed AmountMaximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate.” Balance BillingWhen a provider bills you for the difference between the provider’s charge and the Allowed Amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may Balance Bill you for the remaining $30. A preferred provider, one that is participating in your insurance company’s provider network, can not Balance Bill you for covered services.

10. Copay & Coinsurance / Allowed Amount & Balance Billing Sample from a SBC document:

11. Key Things to Consider When Distinguishing Between Carriers & Benefit Coverage Shopping Readiness

12. Key Questions That Influence An Individual’s Shopping Decisions • What is most important to the person who is looking for a plan? • Are they currently insured? Happy with your current carrier? • Low premium? Low cost-sharing charges? • Providers or Hospital? • What does their budget allow for health coverage? • Is the person eligible for premium credits or cost-sharing reductions? • This may make some coverage tiers (i.e., Silver) more attractive. • What health care does the person expect to use during the year? • Do you have a medical conditions? • Are you or any family member attached to seeing a particular physician?

13. Choosing Your Current Carrier • Is your current carrier offering plans on the Exchange? • If they wish to stay with their current carrier, now it becomes a search for similar out of pocket cost for accessing benefits. • They are currently taking medication, still review the carriers Rx benefit & formulary to confirm the medication is covered at a comfortable out of pocket cost amount. • Formulary is to specify particular medications that are approved to be prescribed under a particular insurance policy. • A carriers formulary and drug coverage level can change based on plan type • Drug coverage levels – Tier 1 Generic, Tier 2 Preferred, Tier 3 Non-Preferred, Tier 4 Specialty Drugs • If they have a chronic medical condition and are continuing to receive care from a specific physician or facility, check the carriers provider directory. • A carriers networks can change based on plan type.

14. Using the Search Functions for Lower Premiums or Lower Cost-sharing • A person can search by: • Provider • Monthly premium • Annual Deductibles • Individual • Family • Annual Out-of-Pocket • Individual • Family • Carrier • Coverage Level • Metal Tiers

15. Advanced Premium Tax Credit (APTC) & Cost Sharing Reduction (CSR) Sample

16. Do You Have a Medical Conditions? • Preexisting conditions can no longer be used to deny coverage or be used to increase their premium. • Do you have a specific physician or facility treating you for this condition? • Do you take certain medications to treat the condition? • The carriers plan benefit page has a link to their formulary • How often do you require testing services? Lab / Radiology ?

17. Are You or a Family Member Attached to a Physician? • OB/GYN? • Primary care physicians • Primary care copay • Children's Pediatrician? • Primary care physicians • Primary care copay • Specialist? • Specialist visit copay • A person could have had a heart condition 10 years ago, but continues to see his Cardiologist once a year for a check up • Some plans may require a Primary care referral to access a Specialist • Hospitals can also play an important role • In their neighborhood • Easy access

18. What Three Factors influence's my premiums? Your Age, Tobacco Use, Location Your age • Rates from 0 to 20 years have the same rate factor, rates for 21 year old to 65 plus year old the rate factors increase every year Tobacco Use • Most plans (not all) increase their rates for tobacco user • Any tobacco use more than 4 times a week over the past 6 months (smoking, electronic cigarettes & chew), but it excludes any tobacco use for religious or ceremonial reasons Your individual rate is based on zip code & county • Colorado has 11 rating areas based on varies counties, determined by the DOI • If your coverage is through your employer, the rate is based on the employer’s zip code & county

19. Actual C4HCO Silver Plan Sample Rates Denver market Age 20 to 21 = 37% increase Other ages vary from 1.3% up to 4.5% Non tobacco to tobacco user 13% increase Age 21 to 65 has a 67% increase Anyone over 65 would receive the same rate

20. What Three Factors influence my premiums? Your Age, Tobacco Use, Location Colorado has 11 rating areas based on varies counties Rating Area 1 & 2 have the lowest rates & Rating Area 11 the highest (rates average about 40% difference) Some zip codes will cross multiple counties

21. Understanding Plan Benefits & Summary of Benefits and Coverage (SBC)

22. Actuarial Value & Metal Tiers What Does Actuarial Value Mean? (Risk sharing between Carrier & members) • The actuarial value of a plan tells you what percentage of health care costs that health insurance plan is expected to pay for its beneficiaries. A plan with an actuarial value of 60 percent (Bronze) is expected to pay approximately 60% of the health care costs of its beneficiaries. The plan’s beneficiaries will pay the other 40% of their health care costs in the form of deductibles, coinsurance and copayments. • Actuarial value is calculated for the health plan as a whole, not for individual members. So, on average across all of a health plan’s subscribers, the actuarial value describes the percentage of health care expenses that will be paid by the plan. However, the percentage of your health care expenses the plan will pay will vary depending on how you use your health insurance. In general: • If you are a LOW health care utilizer and want a plan to cover you for prevention or in case of an emergency – Bronze plans • If you are a HIGH healthcare utilizer – Gold or Platinum plans Metal Tiers • Bronze plans 60% / Silver plans 70% / Gold plans 80% / Platinum plans 90% • Catastrophic (CYA) plans are for individuals under the age of 30OR get a "hardship exemption" from the Federal Government. • Meet all of the requirements applicable to other Qualified Health Plans (QHPs) but that don't cover any benefits other than 3 primary care visits per year before the plan's deductible is met. The premium amount you pay each month for health care is generally lower than for other QHPs, but the out-of-pocket costs for deductibles are generally higher ($6350 / $12700).

23. Cost-Sharing and Metal Tiers ACA Precious Metal Tiers Actuarial value percentages represent how much of a typical population’s medical spending a health insurance plan would cover. In general, lower member cost-sharing and higher premiums Plan Tier Actuarial Value Platinum 90% Gold 80% Silver 70% In general, higher member cost-sharing and lower premiums Bronze 60%

24. Benefit Comparison By Metal Tier

25. Market Place Plan Types Health Maintenance Organization (HMO)A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness. (No Out of Network Coverage) Preferred Provider Organization (PPO)A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals and providers outside of the network for an additional cost. (Out of Network Coverage but at Higher Cost-sharing) Exclusive Provider Organization (EPO) A more restrictive type of preferred provider organization plan under which employees must use providers from the specified network of physicians and hospitals to receive coverage; there is no coverage for care received from a non-network provider except in an emergency situation. (No Out of Network Coverage)

26. Benefit Comparison By HMO & PPO Sample

27. What Applies to Maximum Out-of-Pocket HMO & EPO Plans Copayments Rx Deductibles Rx Copayments Deductibles Coinsurance Rx Coinsurance Maximum Out-of-Pocket $6,350 / $12,700 Prevention

28. What Applies to Maximum Out-of-Pocket HMO & EPO Plans Deductibles Copayments Rx Copayments Coinsurance Out-of-Pocket Limit Maximum Out-of-Pocket $6,350 / $12,700 Prevention

29. What Applies to Maximum Out-of-Pocket PPO Plans In Network Services Out of Network Services Deductibles Copayments Deductibles Rx Copayments Coinsurance Coinsurance Out-of-Pocket Max. Maximum Out-of-Pocket $6,350 / $12,700 Prevention

30. Case Study of How Benefits Accumulate for a Individual Policy Actual C4HCO HMO Silver Plan • Medical Deductible = $2,500 / $5,000 Drug Deductible = $250 Out-of-Pocket Max. = $6,350 / $12,700 • PCP visit = $30 Copay / Specialist = $50 Copay • Prescription Drugs = $15 Generic / $45 (After Ded.) Preferred Brand / 30% (After Ded.) Non-Preferred & Specialty • Facilities = 30% Coinsurance (After Ded.) Outpatient / Inpatient Surgery • Emergency Care = $75 Copay Urgent care center / $400 Copay Emergency Room / 30% coin. (After Ded.) Ambul. • Testing = $300 copay CT/PET Scans, MRIs / 30% coinsurance (After Ded.) X-rays / Lab. This plan has a single Rx Deductible even for family. That means each family member has a $250 Rx deductible

31. Case Study of How Benefits Accumulate for a Catastrophic (CYA) Policy Actual C4HCO Catastrophic (CYA) Plan • Medical Deductible = $6,350 / $12,700 Out-of-Pocket Max. = $6,350 / $12,700 • PCP visit = $35 Copay (limit 3 per year) Specialist = 100% Out-of-pocket / Prescription Drugs = 100% Out-of-pocket • Outpatient / Inpatient Surgery / Emergency Care / CT/PET Scans, MRIs / X-rays / Lab. = 100% Out-of-pocket All plans cover Prevention At no cost All Catastrophic plans cover 3 PCP visits per year not subject to the Deductible

32. Plan Documents Can Be Used at Decision Points Evidence of Coverage, Policy, Summary of Benefits: It’s the members Contract with the carrier (about 80 plus pages) varies by carrier English only Summary of Benefits and Coverage, is a summary of benefits (not a binding contract), standard benefit Layout (9 pages) English & Spanish Company Profile: Standard document Covers – Company at a glance, Medical Loss Ratio, Unique Offerings & Programs, Awards & Recognition,& In the Community. English & Spanish Quality Overview: Standard Document Covers – Accreditations, Consumer Complaints, How the plan makes members healthier / works with providers / examples of innovative approaches, Quality Ratings. English & Spanish Carrier Marketing materials: Not Standard, Varies by carrier English & Spanish

33. Shopping Scenario's

34. Scenario One 33 year old single male, annual income $50,000 per year • No previous health issues, but a tobacco user, averages $150 a year in medical expenses • His primary concern is meeting the new regulation & not having a tax penalty What is he eligible for? • APTC or CSR? NO • Catastrophic plans? NO Plans that meet his decision criteria, • Actual C4HCO Bronze HSA ($200.73) • Ded $5000 / OOP $6350, OV 30% (After Ded), Rx 30% (After Ded) • Actual C4HCO Bronze HMO (227.65) • Ded $6300 / OOP $6300, OV No Charge (After Ded), Rx No Charge (After Ded) • Actual C4HCO Gold HMO ($297.11) • Ded $1600 / OOP $500, OV $15 / $25 copays, Rx $10 / $35 / $60 copays

35. Scenario Two 28 year old single female, annual income $22,000 per year • Previous health issues, averages $5500 a year in medical expenses • Her primary concern is accessing medical services with low OOP expenses What is she eligible for? • APTC or CSR? APTC = $104.65 per month / CSR 87% • Catastrophic plans? Yes Plans that meet her decision criteria, • Actual C4HCO EPO Catastrophic ($143.78) + Medical expenses ($5350) = ($7075) • Ded $6350 / OOP $6350, OV $50 for 3 100% (After Ded), Rx No Charge (After Ded) • Actual C4HCO Bronze HSA ($53.72) + Medical expenses ($5150) = ($5795) • Ded$5000/OOP$6350,OV30%(After Ded)Rx 30%(After Ded)Facility30%(After Ded) • Actual C4HCO Silver HMO ($227.65) + Medical expenses ($2250) = ($4982) • Ded $0 / OOP $2250, OV $15/$25 copay, Rx $15/$45/20% Facility 20% (After Ded)

36. Scenario Three 45 year old single male, Native American, annual income $25,000 per year • Previous health issues, averages $5500 a year in medical expenses • His concern is accessing medical services with low OOP expenses & low premium? • APTC or CSR? APTC = $129.60 CSR = 73% • Native American? Yes • Catastrophic plans? No Plans that meet his decision criteria, • Actual C4HCO Bronze HMO ($92.75) • Ded $0 / OOP $0, OV 0%, Rx 0% • Actual C4HCO Silver HMO ($144.07) • Ded $0 / OOP $0, OV No Charge (After Ded), Rx No Charge (After Ded) • Actual C4HCO Gold HMO ($182.55) • Ded $0 / OOP $0, OV $0 / $0 copays, Rx $0 / $0 / $0 copays

37. Key Takeaways & Considerations Consider Potential Medical Expenses Provider networks Premium isn’t the only consideration in cost Find the Right Mix Premium Plus Out-of-Pocket Medical Expenses