conditional award of 2014 seal of approval (vote)...jun 13, 2013 · •fair marketing practice...

Conditional Award of 2014

Seal of Approval

(VOTE)

The Health Connector Team

Board of Directors Meeting June 13, 2013

Jan 2013

Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec

2014 Seal of Approval (SoA) Timeline

2/15 RFP Launch

5/1 Proposal Due

(Today) Conditional SoA Awarded

7/1 Premium rate filing due to DOI

9/12 Final SoA Awarded

10/1 Open Enrollment Begins

• We are seeking Board approval today to award the conditional Seal of Approval for health and dental benefit plans to be offered through the Health Connector in 2014

• All plans that receive the conditional SoA will be considered for the award of final SoA in September, which requires successful fulfillment of all applicable DOI requirements as well as final approval by this Board

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Objectives of 2014 SoA

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At the core of Health Connector 2.0 strategy…

the 2014 SoA strives to:

• Serve marketplace customers with a vibrant platform of well-designed, market-leading products

• Provide a simple, transparent and consumer-centric shopping experience

• Promote competition and innovation

…with several key levers:

• Preserve and strengthen standardization

• Refresh the standardized portfolio with updated market analysis

• Permit Issuers to additionally propose high-value non-standardized plans

• Expand portfolio to include tiered-copay, catastrophic and dental plans

• Pursue competitive bidding for the State Wrap program

Overall Results

• We are pleased with the SoA results for 2014

• We will have the highest level of Issuer participation ever

– All 9 current participating Issuers of Commonwealth Care/Choice plus one new entrant for medical plans – Minuteman Health

– 5 dental Issuers, all new entrants

• We will be offering a fully-redesigned standardized product platform, developed based on comprehensive market research and featuring a brand-new portfolio designed to appeal to a diverse and evolving market

• Several Issuers (6 medical and 3 dental) proposed additional plans above and beyond the minimum requirements, leveraging the Health Connector as a platform to differentiate and compete

• The Health Connector shelf will include a host of new products for the first time, including tiered-copay plans, catastrophic plans, dental plans and expanded small group options

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5

Qualified Health Plan (QHP) Recommendation

Qualified Dental Plan (QDP) Recommendation

Plan Review Process and Approach

Proposal Summary & Recommendation

Next Steps and Board Vote

SoA Requirement Overview

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ACA Standards for QH/DPs

Health Connector SoA Requirements

QHPs • Licensure and accreditation

• Network adequacy

• Service Area (prohibition on “cherry-picking” against under-served markets)

• EHB, cost-sharing limits and actuarial value requirements

• Premium Review

• Fair marketing practice

• Transparency of coverage

• All other requirements necessary for DOI approval

• Must offer standardized plans

– 2 Platinum, 3 Gold, 1 Silver, 1 Bronze

– At least one each on broadest commercial network

• Option to propose non-standardized plans (certain Issuers required to propose tiered-network plans)

• Each Issuer is required to propose a catastrophic plan

• Each Issuer is required to propose a “wrap-compatible” Silver plan

QDPs • Must offer standardized plans

– Pediatric only, high, and low

• Option to propose non-standardized plans

SoA Review Process

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Conditional SoA Recommendation

3rd-party

review

Cross-functional

PMT

• Led by a cross-functional Procurement Management Team (PMT), representing Plan Management, Operations, Policy and Legal functions

• A close collaboration with DOI to ensure that, subject to final approval, all SoA plans comply with DOI requirements and guidelines

• Supplemented by independent analysis

– Gorman Actuarial (actuarial analysis)

– Boston Benefit Partners (dental)

– Freedman Consulting (service area analysis)

DOI consultation

SoA Review Process (cont’d)

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• A key relevant factor, premium value, is not yet available at this stage

– All QHPs must follow the market-wide DOI rate review process, which approves base rates, plan adjustments and rating factors

– Rate filing is due on July 1st for coverage effective 1/1/2014, with small group and QDP rates subject to quarterly rate review throughout the year

• Conditional SoA takes into consideration anticipated premium value associated with each plan design

– e.g., a proposed plan that features a high-value network is expected to offer a more favorable price point

• The final SoA in September is intended for the Board to approve plans based upon, among other inputs, a review of premium competitiveness of each plan against its design

• Plans that are not awarded conditional SoA today are excluded from our recommendation regardless of their premium value

– e.g., not meeting DOI guidelines; not offering meaningful differentiation

SoA Review Process (cont’d)

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• For standardized and non-standardized plans proposed beyond the minimum requirements, the Health Connector greatly values Issuers’ interest in expanding distribution through the marketplace

• To strike the right balance between optimizing product choice, fostering innovation and maintaining a streamlined marketplace, we applied the following principles in the selection of non-standardized plans:

Each plan must not only meet all QHP/QDP standards on a stand-alone basis, but also add value to the portfolio

Prioritize high-value plans that offer significant differentiation, filling gaps not addressed by standardized plans

Apply a slightly higher “bar” of differentiation for non-group than small group, in an effort to increase choice which is broadly valued by the small group market today

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Summary

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10 Issuers submitted SoA proposals: BCBSMA, BMC HealthNet Plan, CeltiCare, Fallon, HPHC, HNE, Minuteman, NHP, Network Health and THP.

Qualified Health Plans Total

QHPs by Metallic Tier

Plat Gold Silver Bronze

Standardized plans

Required 70 20 30 10 10

Optional 16 4 6 3 3

Recommended 86 24 36 13 13

Non-standardized plans

Small Group

Proposed 25 2 12 6 5


Non-Group

Proposed 20 1 10 4 5


Sub-Total Recommended (by Metallic Tier) 106 26 47 18 15

Catastrophic Plans Recommended 9

Total Recommended 115

Optional Standardized Plans

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2 Issuers proposed a total of 16 optional standardized plans, which we recommend including in the portfolio.

Fallon

CeltiCare

• Fallon proposed 2 additional network options for each of the 7 standardized plan designs

– Select Network (broadest commercial)

– Direct Network (narrower)

– Steward Network (narrower)

• CeltiCare proposed 2 additional standardized plans, one each for the Silver and Bronze tiers

– Both of the optional standardized plans offer adult vision benefits in addition to EHB

Recommended Non-Standardized Plans: Platinum

Plan Feature/ Service Standardized Plans NHP

Plan Name Platinum A Platinum B NHP Platinum Non-Standard 1

NHP Platinum Non-Standard 2

Network Broadest Broadest

Dual/Triple option No No

Small Group only? Small group only Both

Annual Deductible (family=2x) $0 $500 $500 $0

Annual MOOP (family=2x) $2,000 $1,500 $2,000 $1,500

PCP Office Visits $25 $20 $20 $25

Specialist Office Visits $40 $35 $20 $25

Emergency Room $150 $100 √ $100 $100

Inpatient Hospitalization $500 $0 √ $0 √ $250

High-Cost Imaging $150 $100 √ $0 √ $100

Outpatient Surgery $500 $0 √ $0 √ $250

Rx (mail order = 2x)

Retail Tier 1 $15 $15 $15 $15

Retail Tier 2 $30 $25 $25 $30

Retail Tier 3 $50 $45 $45 $50

Recommendation Small group only Small group only

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Check mark (√) indicates that this benefit is subject to the annual deductible

Annual Deductible and Annual Out-of-Pocket Maximum represent individual amounts; family amounts are twice individual amounts, unless stated otherwise

Recommended Non-Standardized Plans: Gold

Plan Feature/ Service Standardized Plans FCHP HPHC NHP

Plan Name Gold A Gold B Gold C 1000 Deductible

2000 Deductible

Best Buy HMO 1000

Best Buy HSA PPO 1500

Gold Non- Std 1

Network Broadest, Direct, Steward Broadest Broadest

Dual/Triple option Yes No No Yes

Small Group only? Both SG only Both Both

Annual Deductible (family=2x) $500 $1,000 $1,500 $1,000 $2,000 $1,000 $1,500 $500

Annual MOOP (family=2x) $3,000 $5,000 $5,000 $4,000 $4,000 $5,000 $5,000 $5,000

PCP Office Visits $20 $30 $25 $25 $25 $20 $0 √ $30

Specialist Office Visits $35 $45 $40 $40 $40 $20 $0 √ $45

Emergency Room 30% √ $150√ $150√ $150 √ $200 √ $100 √ $0 √ $250 √

Inpatient Hospitalization 30% √ $500√ $250√ $500 √ $0 √ $0 √ $0 √ $500 √

High-Cost Imaging 30% √ $200√ $150√ $150 √ $0 √ $0 √ $0 √ $250 √

Outpatient Surgery 30% √ $250√ $250√ $250 √ $0 √ $0 √ $0 √ $250 √

Rx (mail order= 2x)

Retail Tier 1 $15 $20 $15 $5/15 $5/15 $5/20 $5/20 √ $25

Retail Tier 2 50% √ $30 $25 $40 $50 $30 $30 √ $40

Retail Tier 3 50% √ $50 $50 $75 $100 $50 $50 √ $60

Recommendation Both non-group and

small group

Both non-group and

small group

Small group only

Both non-group and

small group

Both non-group and

small group

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Plan Feature/ Service BCBSMA THP

Plan Marketing Name HMO Blue $500 Deductible with Hospital Choice Your Choice HMO (name TBD)

Network Tiered NW that covers broadest commercial Tiered NW that covers broadest commercial

Dual/Triple No No

Small Group only? Both Small Group only

Tier 1 Tier 2 Tier 1 Tier 2 Tier 3

Annual Deductible $500 $250 $1,000 $2,000

Annual Out-of-Pocket Maximum $5,000 (Rx: $1,000)

$6,400 (Rx: $1,400)

PCP Office Visits $20 $25 $35 $45

Specialist Office Visits $35 $35 $45 $55

Emergency Room $100 √ $200 $200 $200

Inpatient Hospitalization $0 √ $1,000 √ $500 √ $750 √ $1,000 √

High-Cost Imaging $100 √ $550 √ $100 √ $350 √ $750 √

Outpatient Surgery $0 √ $1,000 √ $500 √ $750 √ $1000 √

Prescription Drug (mail order = 2x)

Retail Tier 1 $15 $20



Recommendation Both non-group and small group Small group only

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Recommended Tiered Non-Standardized Plans: Gold

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Plan Feature/ Service Std Plan HPHC Minuteman

Plan Name Silver Core Coverage HMO 1750

Best Buy HSA PPO 2000

HMO Non-Std Silver 1

PPO Non-Std Silver 1

PPO Non-Std Silver 2

Network Broadest Broadest Broadest

Dual/Triple option No Yes No No No

Small Group only? Both Both SG only SG only

Annual Deductible (family = 2x) $2,000 $1,750 $2,000 $1,750 $1,750 $2,000

(Rx:$250)

Annual MOOP (family = 2x) $6,400 $5,000 $5,000 $6,350 $6,350 $6,350 (Rx:

$800)

PCP Office Visits $30 $25 1 √ $25 √ $15 2 √ $15 2 √ $30

Specialist Office Visits $50 $25 1 √ $25 √ $45 √ $45 √ $50 √

Emergency Room $350 √ $250 20% √ $350 √ $350 √ $350 √

Inpatient Hospitalization $1,000√ 20% √ 20% √ $1,000 √ $1,000 √ $1,000 √

High-Cost Imaging $400 √ 20% √ 20% √ $400 √ $400 √ $400 √

Outpatient Surgery $750 √ 20% √ 20% √ $750 √ $750 √ $750 √

Rx (mail order = 2x)

Retail Tier 1 $20 $5/20 $5/20 √ $10 $10 $20

Retail Tier 2 $40 50% $30 √ $30 √ $30 √ $40 √

Retail Tier 3 $70 50% $50 √ $50 √ $50 √ $70 √


small group

Both non-group and

small group

Both non-group and

small group

Small group only

Small group only

Recommended Non-Standardized Plans: Silver

1 $25 first 3 medical visits, subsequent visits subject to deductible/20% coinsurance 2 $15 after deductible, 3 PCP visit copays before deductible

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Plan Feature/ Service Std Plan Minuteman NHP

Plan Name Bronze HMO Non-Std Bronze 1 Non-Std Bronze 2

Network Broadest Broadest

Dual/Triple option No Yes

Small Group only? Both Both

Annual Deductible (family=2x) $2,000 $2,000

(Rx: $250) $2,000

(Rx: 250)

Annual MOOP (family=2x) $6,400 $6,350 $6,400

PCP Office Visits $50 √ $50 $50 √

Specialist Office Visits $75 √ $80 √ $80 √

Emergency Room $750 √ $750 √ $750 √

Inpatient Hospitalization $1,000 √ 35% √ $1,000 √

High-Cost Imaging $1,000 √ $1,000 √ $1,000 √

Outpatient Surgery $1,000 √ 35% √ $1,000 √

Rx (mail order=2x)

Retail Tier 1 $30 √ $30 $50 √

Retail Tier 2 50% √ 50% √ $80 √

Retail Tier 3 50% √ 50% √ $120 √


small group Both non-group and

small group

Recommended Non-Standardized Plans: Bronze

Catastrophic Plans

Plan Feature/ Service BCBSMA FCHP HPHC HNE Minuteman NHP THP

Plan Name HMO Blue Essential

FCHP Select Care

Basic Buy 6400

HNE Catastrophic

Plan

Minuteman HMO

Catastrophic Plan

Marketing Name TBD

Marketing Name TBD

Network Broadest Broadest, Direct,

Steward

Broadest Broadest Broadest Broadest Narrower (Select)

Annual Deductible (family=2x)

$6,350

Annual MOOP (family=2x) $6,350

Preventive Services Covered in full

Office Visits

$35 or 50% coinsurance (whichever is lower)

Recommendation Non-group only

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BMCHP, Celticare, and NWH proposed catastrophic plans but have chosen the option to withdraw if the Health

Connector received more than two qualified plans.

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A total of 5 Issuers responded to the QDP RFR, including 3 for small group only, and 2 for both non-group and small group.

Summary

Small group only

Both NG and SG

Standardized Plans Non-Standardized Plans

All Plans Issuers Total

Configurations Total

Configurations

Pedi High Low Pedi High Low

Altus Dental √ 3 1 1 1 3

BCBSMA √ 3 1 1 1 1 1 4

Delta Dental of MA

√ 9 3 3 3 7 5 1 1 16

Guardian √ 3 1 1 1 3

MetLife √ 3 1 1 1 2 1 1 5

Total Proposed 21 7 7 7 10 6 2 2 31

Recommended

Small group only 9 3 12

Both NG and SG 12 7 19

Total 21 10 31

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Network Adequacy Review

Issuer/ Network

Access Points

Unique Providers

(Total)

Unique Providers

(Specialists)

Delta Dental of MA/Premier

8,770 4,943 1,130

BCBSMA Dental Blue

7,696 4,764 1,158

Guardian PPO 5,816 2,498 564

Altus Dental/PPO

5,513 2,698 685

MetLife PPO 4,797 2,175 505

BCBSMA Dental Blue PPO

3,217 1,662 425

Delta Dental of MA/PPO

2,502 1,390 313

Delta Dental of MA/EPO

1,260 777 199

The Health Connector reviewed proposed dental networks for adequacy

• Carriers proposed a range of networks, from extremely broad to limited

• The PMT reviewed multiple metrics

– # of access points

– Unique providers (including specialists)

– Ratio of access points to providers

• Also evaluated distribution of providers within the proposed service area for each network

Recommended Non-Standardized Plans: Pediatric

22 * Deductible and MOOP capped for multiple children.

Plan Feature/Service Standardized Plans

BCBSMA Delta Dental of MA

Plan Name Pediatric EHB Benchmark Plan

Dental Blue Pediatric Essential Benefits

Pediatric Basic Plan (offered on three

networks)

EPO Pediatric Basic Exclusive Network

Plan

EPO Pediatric Exclusive Network

Plan

Proposed for Small group only Both non-group and small group

Network(s) Dental Blue (Broadest)

Premier (Broadest), PPO and EPO

EPO (Limited) EPO (Limited)

Plan Year Deductible $50 $50/$150* $75 $75 $50

Deductible Applies to: Major and Minor Restorative

Major and Minor Restorative




Plan Year Max (>=19 only) N/A N/A N/A N/A N/A

Plan Year MOOP <19 Only $1,000 $1,000/$2,000* $1,000 $1,000 $1,000

Preventive & Diagnostic Co-Insurance In/out-of-Network

0%/20% 0%/20% 0%/20% 0% No OON coverage

0% No OON coverage

Minor Restorative Co-Insurance In/OON

25%/45% 25%/45% 50%/70% 50% No OON coverage

25% No OON coverage

Major Restorative Co-Insurance In/OON

50%/70% 50%/70% 50%/70% 50% No OON coverage

50% No OON coverage

Medically Necessary Orthodontia, <19 only, In/OON

50%/70% 50%/70% 50%/70% 50% No OON coverage

50% No OON coverage

Non-Medically Necessary Orthodontia, <19 only, In/OON

N/A N/A N/A N/A N/A

Recommendation Small group only

Both non-group and small group

Recommended Non-Standardized Plans: Family

Plan Feature/Service Standardized Plans MetLife Delta Dental of MA

Plan Name High Low MA Family High with Enhanced

Child Orthodontia

MA Family Low with Enhanced

Child Orthodontia

EPO Family Enhanced Exclusive

Network Plan

EPO Family Value Exclusive Network Plan

Proposed for Small group only Small group only Non-group & small group

Network(s) PPO PPO EPO (Limited) EPO (Limited)

Plan Year Deductible $50/$150 $50/$150 $50/$150 $75/$225 $50/$150 $50/$150

Deductible Applies to: Major & Minor Restorative

Major & Minor Restorative





Plan Year Max (>=19 ) $1,250 $750 $1,250 In-Network $1,000 OON

$1000 In-network

$750 OON

$1,250 $750

Plan Year MOOP (<19) $1,000/$2,000 $1,000/$2,000 $1,000/$2,000 $1,000/$2,000 $1,000/$2,000 $1,000/$2,000

Preventive & Diagnostic Co-Insurance In/OON

0%/20% 0%/20%

0%/20% 0%/20% 0% No OON coverage

0% No OON coverage

Minor Restorative Co-Insurance In/Out-of-Network

25%/45% 25%/45%

20%/40% 50%/50% 25% No OON coverage

25% No OON

Major Restorative Co-Insurance In/OON

50%/70% 50%/70% No Major

Restorative >=19

50%/70% 50%/70% 50% No OON coverage

50% No OON; No Major Restorative >=19

Medically Necessary Ortho, <19, In/OON

50%/70% 50%/70%

50%/50% 50%/50% 50% No OON

50% No OON

Non-Medically Necessary Ortho, <19 only, In/OON

N/A N/A 50%/50% up to $1,000 lifetime max

50%/50% up to $1,000 lifetime max

N/A N/A

Recommendation Small group only

Small group only

Both non-group and small group

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Next Steps for Awarding the Final Seal of Approval

• We will work closely with the Board through late August/early September to develop recommendations for final award of the SoA

– Issuers must demonstrate compliance with all DOI requirements, including successful completion of premium rate review and with the Health Connector’s contractual requirements

– Our final recommendation will reflect confirmation that all SoA plans must be reasonably priced and offer affordable options through the marketplace

• The final SoA will also incorporate selection of State Wrap Plans

– Wrap Plans are selected based on price competition among the lowest-cost Silver Plans proposed by each Issuer

– In consultation with DOI, Health Connector staff will validate the lowest cost Silver Plan from each QHP Issuer and select up to five (5) Issuers per region to offer Wrap Plans to qualified individuals

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Summary of Recommendation

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• The Health Connector recommends awarding the 2014 Conditional SoA to all proposed standardized QHPs and QDPs and select non-standardized QHPs and QDPs proposed by the following Issuers:

• Altus Dental

• Blue Cross Blue Shield of MA

• BMC HealthNet Plan

• CeltiCare Health Plan

• Delta Dental of MA

• Fallon Community Health Plan

• Guardian

• Harvard Pilgrim Health Care

• Health New England

• MetLife

• Minuteman Health

• Neighborhood Health Plan

• Network Health

• Tufts Health Plan

conditional award of 2014 seal of approval (vote)...jun 13, 2013 · •fair marketing practice...

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