Families USA: Vermont’s Health Care
Exchange Plan Design
Georgia J. Maheras, Esq.
Project Director
Vermont Health Care Innovation Project
January 24, 2014
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FIRST, A LITTLE BACKGROUND
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Some Features of Vermont’s
Health System
14 community hospitals,
including 8 critical access
hospitals (fewer than 25 beds)
1 in-state academic medical
center, plus DartmouthHitchcock, provide most tertiary
care
11 FQHCs serving more than
150,000 Vermonters
Fewer than 2000 physicians,
more than half of whom are
employed
3 health insurance carriers, only 2
in small group market
6.8% uninsured
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Vermont’s Health Reform Goals*
Assure that all
Vermonters have Access
to and Coverage for High
Quality Care
Improve the Health of
Vermonters
Reduce Health Care Costs
and Cost Growth
Assure Greater Fairness
and Equity in How We
Pay for Health Care
*from the State’s Strategic Plan for Health Reform, February, 2012
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Who does what in Vermont health reform
(2012-14)?
Department of VT
Health Access:
Green Mountain
Care Board:
Exchange
Cost Containment
Expansion of
Advanced Primary
Care Practice Model
Payment reform
Governor’s Office: Single
payer financing and
operations
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Vermont Health Reform Timeline
2014
2012
Control costs, pay for value
Design a simpler system of
coverage and financing
Operate Vermont Health
Benefit Exchange: single portal
for insurance for non-group,
small group and public
programs
After ACA waiver is available
(2017?)
Green Mountain Care – unified
system
One payer for most Vermonters
Public financing
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VERMONT’S EXCHANGE REFLECTS
VERMONT’S HEALTH CARE SYSTEM
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Features of Vermont’s Exchange
• Vermont is an ACTIVE purchaser.
• All plans offered to individuals and small businesses
in 2014 will have been selected by Vermont Health
Connect
• Small Business can enroll directly with carriers for
2014
• Define small group at 50 full-time employees or
fewer (2014-2015)
• Individual and small group markets merged
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Vermont’s Process
 Vermont’s Exchange Team developed standardized
plans.
– Listening sessions
– Actuarial support
– Current market scan
 Vermont’s Agency of Administration proposed plans
to the Green Mountain Care Board for approval.
 Green Mountain Care Board held a series of public
meetings and solicited public comment.
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Administration’s Principles for Decision Making
 Creating meaningful choice for consumers
 Encouraging high value services, like primary care and generic
drugs, and innovation – in alignment with State priorities
 Minimizing disruption for small group and individual market
 Maximizing portability of plans, allowing consumers to move
between employer and individual coverage while maintaining
desired plan
 Affordability
 Administrative simplicity
 Maximizing individual premium tax credits
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Administration Stakeholder Input
 Workgroup with a variety perspectives met over last
few months
– Included consumer and patient advocates, brokers,
representatives from insurance companies, providers, and
other interested parties
– Weighed in on number of plans to offer on the Exchange
and the cost-sharing structures they prefer
– Examples of input: priority to low copays for PCP office
visits and generic drugs, certain services before deductible,
include coinsurance to encourage consumer cost
awareness, align cost-sharing within tiers and by services,
offer fewer and distinct plans, allow insurance companies
flexibility
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Approach Recommendations
 A hybrid approach of state-specified plan designs and some
“choice” plans designed by insurance carriers within set
parameters
 4 specified design options across four actuarial levels:
– At Platinum:
1 Specified Plan Design
– At Gold: 1 Specified Plan Design
– At Silver: 2 Specified Plan Designs
– At Bronze:
2 Specified Plan Designs
 Additional “Choice” Plan Designs
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“Choice” Plan Design
The Green Mountain Care Board granted DVHA
authority to approve “Choice” plans
Process:
– State released RFR
– Insurers submitted qualified “choice” plan designs
– DFR reviewed submissions and certified plans
– DVHA selected plans to offer on the Exchange from
certified plans based on specific criteria
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“Choice” Plan Design Criteria
DVHA would used the following criteria in choosing a
“Choice” plan:
 Meaningfully different from standard plans
– Distinct design structure within same AV level, e.g., difference of $500 in
deductible, or an AV that varies by at least 10% for three major service
categories
– Ensures additional plan designs offered will increase the diversity of
options for groups/members
– Both quantitative and non-quantitative differences
 Fosters significant innovations in:
– Wellness promotion - demonstrated experience and success
– Promoting individual engagement in prevention
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Gold
Platinum
Proposed Specified Plan Design Options
1 Specified Design
0 Choice Design
1 Specified Design
1 Choice Design
Total
Specified
Design
Specified
Design
6 Specified Designs
3 Choice Designs (to
be discussed 9/6)
Key:
Circle = State-Specified
Design
Choice Design
Silver
2 Specified Designs
1 Choice Design
Bronze
Square = Insurer Choice
Design
2 Specified Designs
1 Choice Design
Specified
Design 1
Specified
Design 2
Choice Design
Specified
Design 1
Specified
Design 2
Choice Design
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Specified Silver Plans
Deductible/Out of Pocket Maximum
Medical Deductible (Individual/Family)
Rx Deductible
Integrated Deductible
Medical Out of Pocket Maximum
(Individual/Family)
Rx Out of Pocket Maximum
(Individual/Family)
Integrated Out of Pocket Maximum
Family Deductible/Out of Pocket Maximum
Medical Deductible1 waived for:
Drug Deductible waived for:
Service Category
Hospital Services2
Emergency Room 3
Preventive
Silver
Silver
$1900/$3800
$1550/$3100
$100/$200
No
$1250/$2500
Yes
$5100/$10,300
$1250/$2500
No
Stacked, 2x
Individual
Prev, OV, UC,
Amb
Generic scripts
Copay /
Coinsurance
40%
$250
$0
Why these 2 plans?
•Priority for affordable cost$5750/$11,500
sharing for primary care &
$1250/$2500 generic drugs
Rx -No, Medical - Yes •Variation in cost-sharing design
Aggregate, 2x Individual between two plans (mostly copays versus mostly coinsurance)
Preventive
•HDHP plan design qualifies for
Wellness scripts
health savings accounts & health
Copay / Coinsurance reimbursement accounts
20%
20%
0%
Office visit w/PCP or Mental Health
$20
10%
Specialist Office Visit 4
Urgent Care
$40
$60
20%
20%
Ambulance
$100
20%
Rx Drug Coverage
Rx Generic
Rx Preferred Brand
Rx Non-Preferred Brand
$12
$50
50%
$10 VERM ONT HEALTH REFORM
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50%
Vermont Premium Reductions
$300
Vermont’s health care
programs had
premiums that were
more affordable than
the ACA’s APTC.
Premium per Month
$250
$200
$150
$100
$50
$0
100%
150%
200%
250%
FPL
300%
Vermont received
Medicaid match to
reduce the applicable
percentage for
premium payments by
1.5%
ACA Premium
Current Catamount and VHAP premium
Vermont Premium Reduction through Vermont Health Connect
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Vermont Cost Sharing Reductions
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Vermont Cost Sharing Reductions
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