all assister conference call: heath connector 2017 seal of ......aug : sept . oct : nov . dec : 2016...

All Assister Conference Call:

Heath Connector 2017 Seal of Approval Process and Results

HEATHER CLORAN Associate Director of Program and Product Strategy

September 21, 2016

2017 Seal of Approval Timeline

• Each year the Health Connector conducts a comprehensive of review of health and dental plans proposed by health and dental carriers to be sold in the upcoming year on MAhealthconnector.org, which is known as the Seal of Approval process

• On Thursday, September 8, 2016, as part of the 2017 Seal of Approval process, the Health Connector’s Board of Directors approved the health and dental plans to be sold on the marketplace effective January 1, 2017. This approval includes unsubsidized QHPs, QDPs, and the 2016 ConnectorCare program

Mar 2016 Apr May Jun Jul Aug Sept Oct Nov Dec

2016

3/10: SOA Kickoff – Board Meeting

3/18: Release Medical and Dental RFRs

5/13: RFR Responses Due

7/14: Conditional SOA – Board Meeting

11/1: Open Enrollment Begins

9/8: Final SOA – Board Meeting

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What are Qualified Health Plans (QHPs) and Qualified Dental Plans (QDPs)?

• QHP: A health benefit plan that is approved by the MA Division of Insurance for meeting all state and federal requirements, including limits on cost-sharing (e.g., deductibles, copayments, and out-of-pocket maximum amounts) and coverage of essential health benefits, and has received the Health Connector’s Seal of Approval (SoA) as meeting certain standards regarding quality, value, and coverage

• QDP: A dental benefit plan that is approved by the MA Division of Insurance for meeting all state and federal requirements, including reasonable limits on cost-sharing and coverage of the pediatric oral services essential health benefit, and has received the Health Connector’s Seal of Approval as meeting certain standards regarding quality, value, and coverage

What Are QHPs and QDPs?

3

2017 Seal of Approval Overview

The 2017 Qualified Health and Dental Plan available through the Health Connector will offer a range of plan designs, carriers and premiums.

• Rising premium costs, for certain medical carriers and plans, means many members will experience high renewal increases

− Many unsubsidized and APTC-only enrollees, particularly those enrolled in Harvard Pilgrim HealthCare and Neighborhood Health Plan, will see large premium increases for their renewal plans

− Rising premium costs will also impact ConnectorCare members enrolled in higher cost carriers. These members will experience large increases in the contributions for their renewal plans

• Despite these increases, almost all of our enrollees facing steep increases can find similar (or identical) plan options with lower costs from other carriers

− All of our carriers offer networks with high quality providers

− Many enrollees who shop will find plans with lower costs than their renewal plan and their current plan

• The Health Connector will strongly encourage all members to comparison shop in order find a 2017 plan that meets their needs – including cost 4

What are some factors that impact health insurance rates?

Rates

Utilization of health care

services

Rising cost of Rx

Carrier business decisions: changes to

medical policy or admin costs

Adjustments to prior year pricing

Regulatory changes

Rising cost of medical services

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1 Enrollment-weighted premium change (2016 actuals to 2017 calculated) w/ member aging (~2%), assumes mapping to 2017 renewal plan 2 Enrollment-weighted premium change from 2016 ConnectorCare selected Silver plan to 2017 selected Silver plan (2016 actuals to 2017 calculated) w/ member aging (~2%), not directly reflected in member contributions 3 Enrollment-weighted non-group average premiums for Family High and Family Low based on age 20 and over premium value; Pediatric-only based on age less than 20 premium value 4 Enrollment data as of August 2016

Summary of Seal of Approval Results

For 2017, Unsubsidized and APTC-only (i.e., 300-400% of the federal poverty level) members will see significant premium increases, while the ConnectorCare program continues to generate competition on the Silver tier. However, there is significant variation between the premium trends among carriers, with notable outliers.

Changes in Premium: 2016 to 2017

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ConnectorCare Recommendation

ConnectorCare: Overview

The Final SOA also includes the recommendation of those carriers that will participate in the ConnectorCare program, which offers state premium and cost-sharing subsidies for individuals under 300% of the Federal Poverty Level (FPL).

APTC Amount* $192.00

State Premium* Subsidy $53.01

Member Contribution*

$43.00

Cos

t of U

nder

lyin

g

Low

est C

ost S

ilver

Pla

n $2

88.0

1*

• The ConnectorCare selection process reviews the ConnectorCare-compatible Silver plan offerings from each carrier

• The selection criteria to be a ConnectorCare carrier include price competitiveness, provider and facility access, and experience with serving the subsidized population

• Selection of the 2017 ConnectorCare participating carriers is designed to provide continued access to those carriers currently participating in ConnectorCare or the MassHealth MCO program to ensure continuity

ConnectorCare supplements federal Advance Premium Tax Credits (APTC) with State subsidies to create a more

affordable program for eligible MA residents.

*Reflects the cost of subsidizing the lowest cost plan for a 42 year old living in Worcester, earning $20,000 per year or 168.35% FPL, and thus in Plan Type 2B (150-200% FPL). Note: the Member Contribution equals the state affordability schedule amount for that income cohort because this example is subsidizing the lowest cost silver plan available to this person.

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ConnectorCare: 2017 Plan Designs

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ConnectorCare: Recommended Carriers and Regions

Carriers indicated in GREEN have moved to a lower cost position relative to 2016, while carriers indicated in RED have moved to a higher cost position. Prior carrier in rank order position is noted in parentheses. Cluster Lowest Cost 2nd Lowest Cost 3rd Lowest Cost 4th Lowest Cost 5th Lowest Cost

A1 BMCHP (formerly Tufts-Direct)

Tufts-Direct (formerly BMCHP) NHP HNE CeltiCare

A2 BMCHP (formerly Tufts-Direct)

Tufts-Direct (formerly BMCHP) HNE CeltiCare

A3 Tufts-Direct HNE CeltiCare

A4 HNE CeltiCare

B1 BMCHP (formerly Tufts-Direct)

Fallon (formerly NHP)

Tufts-Direct (formerly Fallon)

NHP (formerly BMCHP) CeltiCare

C1 Tufts-Direct BMCHP (formerly Minuteman)

Minuteman (formerly BMCHP) NHP CeltiCare

C21 Tufts-Direct BMCHP (formerly Minuteman)

Minuteman (formerly BMCHP)

Fallon (new entrant) (formerly NHP)

NHP (formerly CeltiCare)2

D1 BMCHP Tufts-Direct Minuteman CeltiCare (formerly NHP)

NHP (formerly CeltiCare)

E1 BMCHP (formerly Tufts-Direct)

Tufts-Direct (formerly BMCHP) Minuteman CeltiCare

(formerly NHP) NHP (formerly CeltiCare)

F1 BMCHP (formerly Tufts-Direct)

Tufts-Direct (formerly BMCHP) Minuteman CeltiCare NHP

F2 CeltiCare NHP

G1 BMCHP (formerly Tufts-Direct)

Tufts-Direct (formerly BMCHP)

CeltiCare (formerly NHP)

NHP (formerly CeltiCare)

G2 NHP

G31 BMCHP (formerly Tufts-Direct)

Tufts-Direct (formerly BMCHP)

Minuteman (new entrant) (formerly NHP) CeltiCare NHP3

1 New Region for 2017 2 CeltiCare no longer selected in new Region C2 due to new entrant (Fallon) 3 NHP moved to higher cost position in new Region G3 due to new entrant (Minuteman)

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ConnectorCare: Enrollee Contributions

ConnectorCare Member Contribution Range for 2017

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We are modifying the premium structure for 2017 to promote the most competitively priced options in the program and avoid additionally subsidizing those plans that filed significant rate increases this year.

ConnectorCare: Enrollee Contributions (cont’d)

• The changes in enrollee contributions, in addition to changes in relative price positioning of the ConnectorCare carriers, will result in a wide range of impacts to members

− Most members enrolled in BMC HealthNet Plan and Tufts Health Plan – Direct, generally the lowest cost plans, will experience either a decrease or a small increase in enrollee contributions for their renewal plan

− Members enrolled in higher cost plans, particularly Neighborhood Health Plan, will see significant increases in contributions for their renewal plan – as high as $165 per month1

• ConnectorCare enrollees facing large increases will be able to shop for a ConnectorCare plan from a different carrier with lower monthly contributions

1 Increase for Neighborhood Health Plan, Plan Type 1, Region G1 2 Expected member-level enrollee contribution change into renewal plan from the same carrier, if available (after APTC and state premium subsidy); percentage values represent proportion of members

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Changes in ConnectorCare Monthly Enrollee Contributions2

Decrease No Change Increase <$10

Increase $10 - $25

Increase $25 - $50

Increase $50 - $75

Increase $75 - $100

Increase >$100

15% 10% 34% 12% 3% 4% 8% 14%

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ConnectorCare: Enhanced Opioid Treatment

The Health Connector will reduce cost burdens for medication-assisted treatment (MAT) and associated services for ConnectorCare enrollees with opioid dependency by setting cost-sharing at zero for medication-assisted treatment (MAT) and associated services, including counseling and drug screening and opioid antagonists for ConnectorCare enrollees • Medication Assisted Treatment (MAT):

− MAT examples include buprenorphine, naltrexone, and methadone

− ConnectorCare Issuers must set medication-assisted treatment medications as zero cost-sharing for all ConnectorCare plan types

− If an identical generic formulation is available, ConnectorCare issuers may set additional cost-sharing for brand formulations

− Any services directly associated with a medication-assisted treatment visit, including counseling and drug screening, must also be provided at zero cost-sharing for all ConnectorCare plan types

− The selected medication(s) and services are not required to be zero-cost sharing on the base Silver plan

− Medication Assisted Treatment (MAT):

• Opioid Antagonists:

− ConnectorCare Issuers must designate at least one (1) opioid antagonist approved for use in take-home setting (e.g., with a standing prescription) as zero cost-sharing for all ConnectorCare plan types

− ConnectorCare Issuers must designate at least one (1) opioid antagonist approved for use by health care professionals as zero cost-sharing for all ConnectorCare plan types

− The selection of the zero cost-sharing medication(s) is at the discretion of the ConnectorCare Issuer

− The selected medication(s) are not required to be zero-cost sharing on the base Silver plan

Qualified Health Plan (QHP) Recommendation

Qualified Health Plans: Product Shelf

Ten (10) medical carriers have a total of sixty-two (62) QHPs for the non-group and small group shelves. • As required, all carriers proposed at least one (1) plan for each of the four (4)

standardized plan designs on the carrier’s broadest commercial network

− Fallon Health proposed standardized plans on alternative networks

− Three carriers requested to waive offering the standardized Bronze plan

• Carriers submitted seventeen (17) non-standardized plans, including five (5) new non-standardized plans for 2017

• Fallon Health has submitted four (4) non-standardized plans offered in 2016 as “frozen plans” for 2017 (i.e., not accepting new enrollments)

• All carriers submitted Catastrophic plans as required, with six (6) carriers requesting to waive their Catastrophic plan offering

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Qualified Health Plans: Product Shelf (cont’d)

The chart below outlines the QHP product shelf proposed for the Health Connector’s consideration for 2017.

Carriers Platinum Gold Silver Bronze Catastrophic Total

Blue Cross Blue Shield 1 1 1 1 1 5

BMC HealthNet Plan 1 1 2 1 0 5

CeltiCare Health 1 1 1 0 0 3

Fallon Health 2 3 (+2 frozen) 4 2

(+2 frozen) 1 12 (+4 frozen)

Health New England 1 4 1 0 0 6

Harvard Pilgrim Health Care 1 2 2 1 0 6

Minuteman Health 2 1 2 2 1 8

Neighborhood Health Plan 1 2 2 1 0 6

Tufts Health Plan - Direct 1 2 2 1 1 7

Tufts Health Plan - Premier 1 1 1 1 0 4

TOTAL 12 18 (+2 frozen) 18 10

(+2 frozen) 4 62 (+4 frozen)

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Qualified Health Plans: 2017 Standardized Designs

Plan Feature/ Service A check mark () indicates that this benefit is subject to the annual deductible

Platinum Gold Silver Bronze

Annual Deductible – Combined N/A $1,000 $2,000 N/A N/A $2,000 $4,000 N/A

Annual Deductible – Medical N/A N/A N/A $2,750 N/A N/A N/A $5,500

Annual Deductible – Prescription Drugs N/A N/A N/A $250 N/A N/A N/A $500

Annual Out-of-Pocket Maximum $3,000 $5,000 $7,150 $7,150 $6,000 $10,000 $14,300 $14,300

Primary Care Provider (PCP) Office Visits $25 $30 $30 $25 Specialist Office Visits $40 $45 $50 $40 Emergency Room $150 $150 $700 $500 Urgent Care $40 $45 $50 $40 Inpatient Hospitalization $500 $500 $1,000 $1,000 Skilled Nursing Facility $500 $500 $1,000 $1,000 Durable Medical Equipment 20% 20% 20% 20% Rehabilitative Occupational and Rehabilitative Physical Therapy $40 $45 $50 $40 Laboratory Outpatient and Professional Services $0 $20 $25 $50 X-rays and Diagnostic Imaging $0 $20 $25 $175 High-Cost Imaging $150 $200 $500 $1,000 Outpatient Surgery: Ambulatory Surgery Center $500 $250 $750 $750 Outpatient Surgery: Physician/Surgical Services $0 $0 $0 $0

Prescription Drug

Retail Tier 1 $15 $20 $20 $25 Retail Tier 2 $30 $30 $60 $75 Retail Tier 3 $50 $50 $90 $100 Mail Tier 1 $30 $40 $40 $50 Mail Tier 2 $60 $60 $120 $150 Mail Tier 3 $150 $150 $270 $300

2017 Final FAVC 91.73% 81.43% 71.84% 61.86% 17

Qualified Health Plans: Unsubsidized & APTC-only Premiums

Unsubsidized and APTC-only members will generally see significant premium increases.

• Overall, Unsubsidized and APTC-only members will see a 19% increase in 20171

− Excluding Neighborhood Health Plan and Harvard Pilgrim plans, outliers with much higher increases, the increase drops to 6.6%1

− These data represent the change in “member-facing” premiums when mapped to the member’s corresponding 2017 plan (e.g., if a member’s 2016 plan is closing, then their experience is captured as the premium increase from the closed plan to their new plan)

Platinum Gold Silver Bronze Catastrophic

5,537 members 9,837 members 28,350 members 6,493 members 573 members

All Plans

Excluding HPHC & NHP

Unsubsidized & APTC-only Average Changes in Premium by Tier: 2016 to 20171

20.8% 14.5% 17.6% 23.3% 4.4%

1 Enrollment-weighted premium change (2016 actuals to 2017 calculated) w/ member aging (~2%), assumes mapping to 2017 renewal plan

4.7% 9.6% 8.8% 8.6% 4.4%

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The premium changes for some plans will be significantly larger than the merged market-wide or Health Connector average increases.

Unsubsidized & APTC-only Average Changes in Premium by Carrier: 2016 to 2017

1 Enrollment data as of August 2016 2 Enrollment-weighted premium change (2016 actuals to 2017 calculated) w/ member aging (~2%), assumes mapping to 2017 renewal plan 3 Premium change reflects HNE 1/1/16 premium submission which contained an error resulting in consumer facing premiums being ~10% lower than intended

Carriers Membership Share1 Premium Change2

Neighborhood Health Plan 28% 24.7%

Tufts Health Plan - Direct 24% 2.6%

Harvard Pilgrim Health Care 17% 47.1%

BMC HealthNet Plan 9% 1.4%

Blue Cross Blue Shield 7% 12.0%

Minuteman Health 5% 9.1%

Tufts Health Plan - Premier 5% 10.4%

Fallon Health 3% 5.4%

Health New England3 3% 17.1%

CeltiCare Health <1% 4.2%

OVERALL 19.0%

Qualified Health Plans: Unsubsidized & APTC-only Premiums (cont’d)

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As part of Open Enrollment, all current members will have the opportunity, and will be encouraged, to shop and compare plans.

Due to the high volume of enrollment in plans experiencing significant premium increases, many subscribers will see large increases in their renewal premiums.

• Most members will be able to shop for a similar or identical plan from a different carrier with lower monthly premiums

1 Enrollment-weighted premium change (2016 actuals to 2017 calculated) w/ member aging (~2%), assumes mapping to 2017 renewal plan

Unsubsidized & APTC-only Average Subscriber-level Changes in Premium: 2016 to 2017 1

Decrease Increase <$10

Increase $10 - $25

Increase $25 - $50

Increase $50 - $75

Increase $75 - $100

Increase $100 - $150

Increase $150 - $200

Increase >$200

9% 17% 9% 11% 10% 9% 12% 9% 16%

Qualified Health Plans: Unsubsidized & APTC-only Premiums (cont’d)

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Qualified Dental Plan (QDP) Recommendation

Qualified Dental Plans: Product Shelf

• All four carriers have submitted at least one offering for each of the required three standardized plan designs: Family High, Family Low and Pediatric-only

• Four non-standardized plan designs have been proposed by two carriers

− Delta Dental proposed three non-standardized plans and Blue Cross Blue Shield of MA proposed one non-standardized plan, all previously offered in 2016

Carriers Non-Group

Small Group

Standardized Plans Non-Standardized Plans All Plans

High Low Pedi Total High Low Pedi Total

Altus Dental 1 1 1 3 - - - 0 3

Blue Cross Blue Shield of MA 1 1 1 3 - - 1 1 4

Delta Dental of MA 2 2 2 6 - 1 2 3 9

Guardian 1 1 1 3 - - - 0 3

Standardized Plans Non-Standardized Plans All Plans

Non-Group 9 3 12

Small Group 15 4 19 22

Overall, non-group members enrolled in QDPs will see an average decrease in premiums of 7.3%, with those enrolled in Family Low and Pediatric-only products experiencing larger decreases.1

Qualified Dental Plans: Non-group Premiums

Non-group Dental Average Changes in Premium by Tier: 2016 to 2017 1

Family High Family Low Pediatric-only

16,912 members2 43,783 members 629 members

5.3% 12.2% 25.0%

Non-group Dental Average Changes in Premium by Carrier: 2016 to 2017

1 Enrollment-weighted non-group average premiums for Family High and Family Low based on age 20 and over premium value; Pediatric-only based on age less than 20 premium value 2 Enrollment as of August 8, 2016

Carriers Membership Share2 Premium Change1

Altus Dental 16% 12.0%

Delta Dental of MA 84% -10.8%

OVERALL -7.3%

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Qualified Dental Plans: Renewal Approach

More than 99% of dental members will be renewed into the same plan as 2016, with a majority of members seeing a decrease in their premiums for 2017. • For the very limited enrollment in the one closing QDP, members will be mapped

to the lowest cost plan from the same carrier in the Pediatric-only tier

Renew into Same Plan

99.90%

Plan Closing (Market-wide)

0.10%

QDP Renewal Status for 2017 (Members)1

1 Enrollment as of August 8, 2016 24

Member Communications Approach

Comparison Shopping: Planned Communications

During this year’s Open Enrollment, all member communications will strongly encourage shopping as the best way to find a good “deal” for 2017.

• In addition to promoting shopping, we will be encouraging members to get help from Enrollment Assisters, and to take advantage of our decision support tools (e.g., shopping guides, provider search, etc.)

• We will be sending communications including emails, personalized letters, special inserts into monthly bills, and may deploy a robo-call campaign to encourage shopping

• Key Messages include:

− Highlighting potential changes in monthly premiums, but making clear that there are options available offering the same or similar benefits

− The Health Connector has tools to help you find a good, affordable plan with access to excellent care

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Comparison Shopping: Key Messages

“We know you might be facing significant changes in your plan for 2017, but

we are here to help.”

“All of our plans include access to quality doctors, hospitals and other

medical care in your area. If you think it might be time to consider a new plan, you can use our tools to find a new doctor that can give you

the care you need.”

“For many people, there are opportunities to find a plan that

includes the same level of benefits and access to care, but at a lower cost. It can be worth taking a few

minutes to review your options and save hundreds of dollars over the

course of the year.”

“We know this can be a confusing and stressful process, but help is available. We have walk-in centers and community organizations around the state with staff who are trained and

ready to help you pick the right plan.”

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Assister Resources

Health Connector shopping courses

In advance of this year’s Open Enrollment, new interactive lessons on Health Connector shopping will be available in the Learning Management System (LMS).

• The Health Connector considered feedback from stakeholders including Advocates, Navigators and Certified Application Counselors and created three distinct lessons:

1. An Assister's Guide Health Insurance Literacy

2. An Assister's Guide to Shopping for and Enrolling in Health Connector Plans

3. An Assister's Guide to Shopping for and Enrolling in ConnectorCare Plans

• Assisters can expect to these courses to be available in mid to late October

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This tool and other resources are available for download from: https://www.mahealthconnector.org/help-center/resource-download-center

Health Plan Shopping Guide

• Use this guide when helping a consumer with shopping. It is helpful to mail or give to the Consumer before their appointment so they can complete the worksheet and bring it with them to their appointment

• The worksheet contains information specific to their health care needs such as: o How often they use specific health care

services o Names of doctors or specialists they or

anyone on their plan want to be able to see o Names of hospitals or health centers that

they or anyone on their plan want to be able to go to for care

o Names of prescription medications they or anyone on their plan take regularly

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https://www.mahealthconnector.org/help-center/resource-download-center







Provider Directory

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• Remind consumers that provider networks vary by insurance carrier

• Consumers can check to see if a provider is in a plan’s network in the following three ways:

1. Use the Find a Provider tool located on the Health Connector’s website at ProviderDirectory.MAhealthconnector.org

2. Check the provider directory located on the insurance plan’s website

3. Call the insurance plan directly and speak to a customer representative

http://providerdirectory.mahealthconnector.org/ma/

http://providerdirectory.mahealthconnector.org/ma/

Certain providers such as behavioral health providers and Community Health Centers are not currently listed in the directory

Provider Directory (cont’d)

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Appendix: ConnectorCare Enrollee Contributions

2017 ConnectorCare Enrollee Contributions (FINAL)

Region A1 Enrollee Premium Contribution By Plan Type

1 <100%FPL

2A 100-150% FPL

2B 150-200% FPL

3A 200-250% FPL

3B 250-300% FPL

1 BMC $0 $0 $43 $83 $124

2 Tufts-Direct $0 $9 $56 $113 $157

3 NHP $111 $113 $159 $203 $247

4 HNE $152 $155 $201 $247 $293

5 CeltiCare $160 $162 $209 $255 $301


1 2A 2B 3A 3B

1 BMC $0 $0 $43 $83 $124

2 Tufts-Direct $0 $9 $56 $113 $157

3 HNE $152 $155 $201 $247 $293

4 CeltiCare $160 $162 $209 $255 $301


1 2A 2B 3A 3B

1 Tufts-Direct $0 $0 $43 $83 $124

2 HNE $118 $120 $166 $210 $255

3 CeltiCare $125 $127 $173 $218 $263


1 2A 2B 3A 3B

1 HNE $0 $0 $43 $83 $124

2 CeltiCare $0 $2 $46 $90 $131

Region B1 Enrollee Premium Contribution By Plan Type

1 2A 2B 3A 3B

1 BMC $0 $0 $43 $83 $124

2 Fallon $0 $1 $44 $85 $126

3 Tufts-Direct $0 $1 $44 $86 $127

4 NHP $53 $53 $97 $138 $180

5 CeltiCare $84 $85 $129 $172 $214

Region C1 Enrollee Premium Contribution By Plan Type

1 2A 2B 3A 3B

1 Tufts-Direct $0 $0 $43 $83 $124

2 BMC $0 $1 $44 $86 $127

3 Minuteman $43 $42 $85 $126 $167

4 NHP $120 $118 $161 $203 $245

5 CeltiCare $125 $122 $166 $207 $249

Region D1 Enrollee Premium Contribution By Plan Type

1 2A 2B 3A 3B

1 BMC $0 $0 $43 $83 $124

2 Tufts-Direct $0 $6 $51 $100 $143

3 Minuteman $54 $53 $97 $138 $180

4 CeltiCare $104 $103 $147 $189 $231

5 NHP $130 $129 $174 $216 $259

Region E1 Enrollee Premium Contribution By Plan Type

1 2A 2B 3A 3B

1 BMC $0 $0 $43 $83 $124

2 Tufts-Direct $0 $4 $49 $96 $137

3 Minuteman $42 $42 $85 $125 $166

4 CeltiCare $150 $149 $193 $233 $274

5 NHP $152 $150 $194 $234 $276

Region F1 Enrollee Premium Contribution By Plan Type

1 2A 2B 3A 3B

1 BMC $0 $0 $43 $83 $124

2 Tufts-Direct $0 $2 $46 $89 $131

3 Minuteman $0 $8 $54 $107 $150

4 CeltiCare $82 $82 $126 $168 $210

5 NHP $133 $132 $177 $221 $263

Region F2 Enrollee Premium Contribution By Plan Type

1 2A 2B 3A 3B

1 CeltiCare $0 $0 $43 $83 $124

2 NHP $51 $50 $94 $136 $177

Region G1 Enrollee Premium Contribution By Plan Type

1 2A 2B 3A 3B

1 BMC $0 $0 $43 $83 $124

2 Tufts-Direct $0 $1 $44 $84 $125

3 CeltiCare $59 $62 $106 $147 $188

4 NHP $165 $174 $221 $263 $305


1 2A 2B 3A 3B

1 NHP $0 $0 $43 $83 $124

Region C2 Enrollee Premium Contribution By Plan Type

1 2A 2B 3A 3B

1 Tufts-Direct $0 $0 $43 $83 $124

2 BMC $0 $1 $44 $86 $127

3 Minuteman $43 $42 $85 $126 $167

4 Fallon $66 $64 $107 $148 $190

5 NHP $120 $118 $161 $203 $245


1 2A 2B 3A 3B

1 BMC $0 $0 $43 $83 $124

2 Tufts-Direct $0 $1 $44 $84 $125

3 Minuteman $0 $3 $46 $90 $132

4 CeltiCare $59 $62 $106 $147 $188

5 NHP $165 $174 $221 $263 $305

Appendix: Non-standardized QHPs

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Proposed 2017 Non-standardized QHPs – Platinum


Platinum Standard Minuteman MyDoc HMO Platinum Extra Value

Annual Deductible – Combined N/A N/A N/A N/A

Annual Out-of-Pocket Maximum $3,000 $6,000 $6,000 $12,000

PCP Office Visits $25 $5 Specialist Office Visits $40 $15 Emergency Room $150 $250 Urgent Care $40 $5 Inpatient Hospitalization $500 $1,000 Skilled Nursing Facility $500 $1,000 Durable Medical Equipment 20% 20% Rehabilitative Occupational and Rehabilitative Physical Therapy $40 $15 Laboratory Outpatient and Professional Services $0 $25 X-rays and Diagnostic Imaging $0 $50 High-Cost Imaging $150 $250 Outpatient Surgery: Ambulatory Surgery Center $500 $500 Outpatient Surgery: Physician/Surgical Services $0 $0

Prescription Drug

Retail Tier 1 $15 $5 Retail Tier 2 $30 $25 Retail Tier 3 $50 $50 Mail Tier 1 $30 $10 Mail Tier 2 $60 $50 Mail Tier 3 $150 $100

2017 Final FAVC 91.73% 91.12%

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Proposed 2017 Non-standardized QHPs – Gold


Gold Standard Fallon Direct Care Deductible Hybrid

2000 HNE Gold A HNE Essential

2000 HNE Wise Max

HDHP

Annual Deductible – Combined $1,000 $2,000 $500 $2,000 $2,000 $2,000 $4,000 $1,000 $4,000 $4,000

Annual Out-of-Pocket Maximum $5,000 $6,850 $5,000 $5,000 $5,000

$10,000 $13,700 $10,000 $10,000 $10,000 PCP Office Visits $30 $5 $20 $25 $0 Specialist Office Visits $45 $15 $35 $25 $0 Emergency Room $150 $250 30% $200 $0 Urgent Care $45 $5 $40 $25 $0 Inpatient Hospitalization $500 $1,000 30% $0 $0 Skilled Nursing Facility $500 $10,00 30% $0 $0 Durable Medical Equipment 20% 20% 20% 20% $0 Rehabilitative Occupational and Rehabilitative Physical Therapy $45 $15 $35 $25 $0 Laboratory Outpatient and Professional Services $20 $0 $20 $0 $0 X-rays and Diagnostic Imaging $20 $0 $20 $0 $0 High-Cost Imaging $200 $350 30% $100 $0 Outpatient Surgery: Ambulatory Surgery Center $250 $500 30% $0 $0 Outpatient Surgery: Physician/Surgical Services $0 $0 $0 $0 $0

Prescription Drug

Retail Tier 1 $20 $5 $15 $15 $15 Retail Tier 2 $30 $30 $50 $50 $25 Retail Tier 3 $50 50% $100 $75 $50 Mail Tier 1 $40 $10 $30 $30 $30 Mail Tier 2 $60 $60 $100 $100 $50 Mail Tier 3 $150 50% $200 $150 $100

2017 Final FAVC 81.43% 80.59% 81.68% 80.63% 79.13%

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Proposed 2017 Non-standardized QHPs – Gold (cont’d)


Gold Standard HPHC Best Buy HMO 2000

NHP PRIME HMO 500/1000 20/35 30%

FLEXRX 4-TIER

Tufts Direct Gold 500 with Coinsurance

Annual Deductible – Combined $1,000 $2,000 $500 $500 $2,000 $4,000 $1,000 $1,000


$10,000 $10,500 $6,000 $6,500 PCP Office Visits $30 $25 $20 $20 Specialist Office Visits $45 $40 $35 $35 Emergency Room $150 $200 30% 30% Urgent Care $45 $40 $35 $35 Inpatient Hospitalization $500 $250 30% 30% Skilled Nursing Facility $500 $250 30% 30% Durable Medical Equipment 20% 20% 30% 30% Rehabilitative Occupational and Rehabilitative Physical Therapy $45 $25 $35 $35 Laboratory Outpatient and Professional Services $20 $25 $35 $0 X-rays and Diagnostic Imaging $20 $25 $35 30% High-Cost Imaging $200 $200 30% 30% Outpatient Surgery: Ambulatory Surgery Center $250 $200 30% 30% Outpatient Surgery: Physician/Surgical Services $0 $0 30% 30%

Prescription Drug

Retail Tier 1 $20 $15 $15 $15 Retail Tier 2 $30 $40 50% 50% Retail Tier 3 $50 $70 50% 50% Mail Tier 1 $40 $30 $30 $30 Mail Tier 2 $60 $80 50% 50% Mail Tier 3 $150 $140 50% 50%

2017 Final FAVC 81.43% 78.01% 81.32% 81.38%

39

Proposed 2017 Non-standardized QHPs – Silver


Silver Standard BMC HealthNet Plan Silver B

Fallon Community Care Silver

Coinsurance 35%

Fallon Select Care Silver Coinsurance

35%

HPHC Core Coverage HMO

1750

Annual Deductible – Combined $2,000 $3,000 $2,000 $2,000 $1,750 $4,000 $6,000 $4,000 $4,000 $3,500

Annual Out-of-Pocket Maximum $7,150 $7,150 $7,150 $7,150 $6,400

$14,300 $14,300 $14,300 $14,300 $12,800

PCP Office Visits $30 $30 $30 $30 $35 before

deductible, 20% after deductible

Specialist Office Visits $50 $50 $50 $50 $35 before


Emergency Room $700 $500 35% 35% $250

Urgent Care $50 25% $30 $30 $35 before


Inpatient Hospitalization $1,000 25% $1,000 $1,000 20% Skilled Nursing Facility $1,000 25% $1,000 $1,000 20% Durable Medical Equipment 20% 30% 35% 35% 20%

Rehabilitative Occupational and Rehabilitative Physical Therapy $50 $50 $50 $50 $35 before


Laboratory Outpatient and Professional Services $25 25% 35% 35% 20% X-rays and Diagnostic Imaging $25 25% 35% 35% 20% High-Cost Imaging $500 25% $500 $500 20% Outpatient Surgery: Ambulatory Surgery Center $750 $750 35% 35% 20% Outpatient Surgery: Physician/Surgical Services $0 $0 35% 35% 20%

Prescription Drug

Retail Tier 1 $20 $30 $20 $20 $5 Retail Tier 2 $60 35% 50% 50% $80 Retail Tier 3 $90 35% 50% 50% $110 Mail Tier 1 $40 $60 $40 $40 $10 Mail Tier 2 $120 35% 50% 50% $160 Mail Tier 3 $270 35% 50% 50% $220

2017 Final FAVC 71.81% 68.30% 69.39% 69.39% 71.99%

40

Proposed 2017 Non-standardized QHPs – Silver (cont’d)


Silver Standard Minuteman MyDoc HMO Silver Plus

NHP PRIME HMO 2000/4000 30/50 35%

FLEXRX 4-TIER

Tufts Direct Silver 2200 with

Coinsurance

Annual Deductible – Combined $2,000 $2,000 $2,000 $2,200 $4,000 $4,000 $4,000 $4,400


$14,300 $14,300 $13,700 $14,300 PCP Office Visits $30 $15 $30 $50 Specialist Office Visits $50 $45 $50 $75 Emergency Room $700 $350 35% $500 Urgent Care $50 $15 $50 $75 Inpatient Hospitalization $1,000 $1000 35% 20% Skilled Nursing Facility $1,000 $1000 35% 20% Durable Medical Equipment 20% 20% 35% 30% Rehabilitative Occupational and Rehabilitative Physical Therapy $50 $45 $50 $75 Laboratory Outpatient and Professional Services $25 $50 $50 $0 X-rays and Diagnostic Imaging $25 $150 $50 20% High-Cost Imaging $500 $400 35% 20% Outpatient Surgery: Ambulatory Surgery Center $750 $750 35% $750 Outpatient Surgery: Physician/Surgical Services $0 $0 35% $0

Prescription Drug

Retail Tier 1 $20 $13 $30 $35 Retail Tier 2 $60 $30 35% 50% Retail Tier 3 $90 $50 35% 50% Mail Tier 1 $40 $26 $60 $70 Mail Tier 2 $120 $60 35% 50% Mail Tier 3 $270 $100 35% 50%

2017 Final FAVC 71.81% 70.89% 68.88% 68.12%

41

Proposed 2017 Non-standardized QHPs – Bronze


Bronze Standard #1

Minuteman MyDoc HMO Bronze 2500

Tufts Premier Bronze Saver 3300

Annual Deductible – Combined N/A $3,000 $3,300 N/A $6,000 $6,600

Annual Deductible – Medical $2,750 N/A N/A $5,500 N/A N/A

Annual Deductible – Prescription Drugs $250 N/A N/A $500 N/A N/A

Annual Out-of-Pocket Maximum $7,150 $7,150 $6,550

$14,300 $14,300 $13,100 PCP Office Visits $25 $25 $40 Specialist Office Visits $40 $50 $65

Emergency Room $500 $750 $750

Urgent Care $40 $25 $65 Inpatient Hospitalization $1,000 $1,000 $1,000 Skilled Nursing Facility $1,000 $1,000 $0 Durable Medical Equipment 20% 20% 30% Rehabilitative Occupational and Rehabilitative Physical Therapy $40 $50 $65 Laboratory Outpatient and Professional Services $50 $50 40% X-rays and Diagnostic Imaging $175 $175 40% High-Cost Imaging $1,000 $1,000 $750 Outpatient Surgery: Ambulatory Surgery Center $750 $1,000 $1,000 Outpatient Surgery: Physician/Surgical Services $0 $0 $0

Prescription Drug

Retail Tier 1 $25 $30 $35 Retail Tier 2 $75 $75 $100 Retail Tier 3 $100 $100 $150 Mail Tier 1 $50 $60 $70 Mail Tier 2 $150 $150 $200 Mail Tier 3 $300 $200 $300

2017 Final FAVC 61.86% 61.28% TBD

Appendix: Frozen QHPs

Proposed 2017 Frozen QHPs


Fallon Direct Care Gold Connector A

Fallon Select Care Gold Connector A

Fallon Direct Care Bronze Deductible

3000

Fallon Select Care Bronze Deductible

3000

Annual Deductible – Combined $500 $500 $3,000 $3,000

$1,000 $1,000 $6,000 $6,000

Annual Out-of-Pocket Maximum $3,000 $3,000 $7,150 $7,150 $6,000 $6,000 $14,300 $14,300

PCP Office Visits $20 $20 $60 $60 Specialist Office Visits $35 $35 $75 $75 Emergency Room 35% 35% $1,000 $1,000 Urgent Care $20 $20 $60 $60 Inpatient Hospitalization 30% 30% $1,000 $1,000 Skilled Nursing Facility 30% 30% $1,000 $1,000 Durable Medical Equipment 30% 30% 30% 30% Rehabilitative Occupational and Rehabilitative Physical Therapy $20 $20 $75 $75 Laboratory Outpatient and Professional Services 35% 35% $50 $50 X-rays and Diagnostic Imaging 35% 35% $175 $175 High-Cost Imaging 35% 35% $850 $850 Outpatient Surgery: Ambulatory Surgery Center 30% 30% 35% 35% Outpatient Surgery: Physician/Surgical Services 30% 30% 35% 35%

Prescription Drug

Retail Tier 1 $15 $15 $40 $40 Retail Tier 2 50% 50% $100 $100 Retail Tier 3 50% 50% $100 $100 Mail Tier 1 $30 $30 $80 $80 Mail Tier 2 50% 50% $200 $200 Mail Tier 3 50% 50% $200 $200

2017 Final FAVC 81.68% 81.68% 61.80% 61.80%

43

Appendix: QDPs

Qualified Dental Plans: 2017 Standardized Designs

Plan Feature/ Service Family High Family Low Pediatric-only Plan Year Deductible $50/$150 $50/$150 $50

Deductible Applies to Major and Minor Restorative

Major and Minor Restorative


Plan Year Max (>=19 only) $1,250 $750 N/A

Plan Year MOOP <19 Only $350 (1 child) $700 (2+ children)

$350 (1 child) $700 (2+ children) $350 (1 child)

Preventive & Diagnostic Co-Insurance (In/out-of-Network) 0%/20% 0%/20% 0%/20% Minor Restorative Co-Insurance (In/out-of-Network) 25%/45% 25%/45% 25%/45%

Major Restorative Co-Insurance (In/out-of-Network) 50%/70% 50%/70%

No Major Restorative >=19

50%/70%

Medically Necessary Orthodontia, <19 only (In/out-of-Network) 50%/70% 50%/70% 50%/70%

Non-Medically Necessary Orthodontia, <19 only (In/out-of-Network) N/A N/A N/A

45

46

Non-Standardized QDPs

Plan Feature/ Service Family Low Standard Design Delta Dental EPO Family Basic Exclusive Network Plan

Plan Year Deductible $50/$150 $100/$300

Deductible Applies to Major and Minor Restorative Major & Minor Restorative

Plan Year Max (>=19 only) $750 $750

Plan Year MOOP <19 Only $350 (1 child) $700 (2+ children)

$350 (1 child)/ $700 (2+ children)

Preventive & Diagnostic Co-Insurance In/out-of-Network 0%/20% 0% In-Network, No Out-Of-Network Minor Restorative Co-Insurance In/out-of-Network 25%/45% <19-EHB-60% In-Network, No Out-Of-Network

>=19-70% In-Network, No Out-Of-Network

Major Restorative Co-Insurance In/out-of-Network

50%/70% No Major Restorative

>=19

60% In-Network, No Out-Of-Network No Major Restorative >=19

Medically Necessary Orthodontia, <19 only, In/out-of-Network 50%/70% 60% In-Network, No Out-Of-Network

Plan Feature/ Service Pediatric-only Standard Design

Blue Cross Blue Shield Dental Blue Pediatric Essential

Benefits

Delta Dental EPO Pediatric Basic

Delta Dental EPO Pediatric Exclusive

Network Plan

Plan Year Deductible $50 $50 $100 $50

Deductible Applies to Major and Minor Restorative




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

Plan Year MOOP <19 Only $350 (1 child) $350 (1 child) $350 (1 child) $350 (1 child)

Preventive & Diagnostic Co-Insurance In/out-of-Network 0%/20% 0% In-Network No Out-Of-Network 0%/20% 0% In-Network

No Out-Of-Network Minor Restorative Co-Insurance In/out-of-Network 25%/45% 25% In-Network

No Out-Of-Network 60%/70% 25% In-Network No Out-Of-Network

Major Restorative Co-Insurance In/out-of-Network 50%/70% 50% In-Network


Medically Necessary Orthodontia, <19 only, In/out-of-Network 50%/70% 50% In-Network


all assister conference call: heath connector 2017 seal of ......aug : sept . oct : nov . dec : 2016...

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