enhancing the patient-centeredness of state health insurance markets

8/20/2019 Enhancing the Patient-Centeredness of State Health Insurance Markets

1/118ENHANCING THE PATIENT-CENTEREDNESS OF STATE HEALTH INSURANCE MARKETS · 1

Enhancing the Patient-Centeredness

of State Health Insurance Markets

State Progress Reports


2/1182 · ENHANCING THE PATIENT-CENTEREDNESS OF STATE HEALTH INSURANCE MARKETS

Founded in 1920, the NHC is the only organization that brings together all segments

of the health community to provide a united and effective voice for the more

than 133 million people living with chronic diseases and disabilities and their familycaregivers. Made up of more than 100 national health-related organizations

and businesses, its core membership includes the nation’s leading patient

advocacy organizations, which control its governance. Other members include

professional and membership associations, nonprofit organizations with an

interest in health, and major pharmaceutical, health insurance, medical device,

and biotechnology companies.

The National Health Council State Progress Reports are made possible

with the generous support from the initiative’s premier sponsor,

Novartis Pharmaceuticals Corporation.

Additional support is provided by:

AstraZeneca Pharmaceuticals

Celgene Corporation

Genentech

Johnson & Johnson



A Message for Members and Par tners /

Te National Health Council (NHC) and its members are committed supporters of

Affordable Care Act (ACA) provisions that provide the greatest benefit to people with

chronic diseases and disabilities. Since the passage of the ACA, the NHC has worked to

strengthen these protections so that patients can access health insurance that meets both

their health and budget needs. As members and partners of the NHC, you and your organizations can help carry this

message to state policymakers and regulators. Te ACA’s insurance market reforms, coverage

expansions, and subsidies are significant steps forward for the patient community. However,

the successful implementation of these steps relies on states to continue and even expand

their role as regulators of their health insurance market. State support is critical to guarantee-

ing the ACA’s goals of high-quality and affordable health care for all.

Tese state Progress Reports illustrate the variability of the patient-centeredness of health

insurance markets across states. Members, partners, and the NHC will use these reports to

identify states where changes could improve access to coverage and care for patients. Tese

reports also can identify leading states that set best practices for patient-friendly requirements.

Remember, the specific reforms that are appropriate to one state may not be the right fit forall states. Te goal of these reports is to encourage states to implement a range of reforms in

the key areas that will have the most benefit to patients—non-discrimination, transparency,

oversight, uniformity, and continuity of care.

Your actions to move these policies forward can have a lasting effect on the lives of all patients.

Background /

Exchange Operational Models

Te ACA established sweeping insurance reforms that included the introduction of health

insurance exchanges, where individuals and families can shop for health insurance coverage.

While each state has its own exchange, the federal government plays a role in managingexchanges in many states. In general, states followed one of three paths to establish an

exchange—a state-based exchange, a state-partnership exchange in which the state and

federal government share exchange responsibilities, or a federally-facilitated exchange. Each

model envisions a different role for states, and, as a result, the federal government. However,

the federal government sets basic operating standards for all exchanges.

STATE-

BASED

EXCHANGE

STATE

PARTNERSHIP

EXCHANGE

FEDERALLY-

FACILITATED

EXCHANGE

NUMBER OF STATES 16 + DC 6 29

Plan Management

State

State

FederalConsumer Assistance

Eligibility and EnrollmentFederal

Financial Management



1 Five states (Alabama, Missouri, Oklahoma, exas, and Wyoming) have declined to play any role in oversightor enforcement of the ACA.

The Role of States

Each exchange model relies on states to ensure that plans comply with state insurance laws

and to enforce some aspects of the ACA.1 Terefore, every state has the opportunity to

establish additional standards and requirements that ensure patients have access to coverage

that meets their needs.

Project Purpose /

Tese Progress Reports aim to identify the state-by-state variation in patient friendliness of

insurance exchanges to:

• Promote policies that help protect patients, and

• Discourage policies that are inconsistent with patient needs.

Methodology and Sources /

Te National Health Council (NHC) works to ensure that the protections put in place by

the ACA are implemented in the best interest of patients. As part of these efforts, the NHC

prioritizes five key prin ciples of a truly patient-focused insurance market—non-discrimination,

transparency, oversight, uniformity, and continuity-of-care.

Non-discrimination

Confirm plan designs do not discriminate or impede access to care, including a provider

network that ensures patients can access care when they need it.

Tra nsparency

Provide access to clear and accurate information for consumers about covered services and

costs in exchange plans, including a user-friendly exchange website.

State oversight

Ensure all exchange plans meet applicable state and federal requirements, including the

state’s plan management requirements and rate review.

Uniformity

Create standards to make it easier for patients to compare exchange plans, such as a quality

scorecard and standardized plan materials.

Continuity of care

Broaden sources of coverage and protect patients transitioning between plans, including

expanded Medicaid.

o understand how insurance markets perform against these priorities, the reports assess

each state using a set of metrics. Te metrics represent specific, measurable, and actionable

goals for each state’s insurance market and exchange.

States are assigned scores for each metric, based on an evaluation of the state’s action or

market in relation to its effect on patients:

Beneficial scores are assigned to states with policies or insurance market dynamics

resulting in better access or choice for patients.

Neutral scores are assigned to states without policies that result in better access or

choice for patients.

Negative scores are assigned to states with policies or insurance market dynamics

resulting in reduced access or choice for patients.



Ten, the Progress Reports compare performance on all metrics within each principle across

states, yielding state-by-state assessments for all five principles. Tis step determines whether

states are high-performing, average-performing, or low-performing for each principle.

Te analysis is based on a proprietary database of policy developments for all 50 states and

the District of Columbia, maintained by Avalere Health. Progress Reports also reference

publicly available resources, cited where applicable. Te score for each metric was based on

states’ performance as of January 1, 2015. Tese reports reflect policies in effect for the 2015

exchange market and do not include proposed measures or actions. Additionally, Avalere

conducted a focused review of selected topics for state exchange insurance markets, though

this assessment is not intended to be a comprehensive review of all legislation and regulations

pertaining to states’ insurance markets.

Promising Practices across States /

While all states have taken steps to enhance the patient experience, some states have set

particularly high standards for patient-centered exchange markets. In fact, the states high-

lighted below have implemented policies that represent models for other states considering

changes to their insurance markets

Non-discrimination

Since the launch of exchanges, there has been limited federal and state action to examine

plan benefits for discrimination. Currently, most states follow guidance from the federal

government to ensure that exchange plan benefits are not discriminatory. Some states have

enacted measures to limit opportunities for discrimination in the exchanges and to ensure

patients have adequate access to services and providers.

Washington, an SBE, is a leader in fighting discrimination in the exchange market,

receivingbeneficial scores across each non-discrimination metric. Specifically,

Washington issued regulations that limit discrimination in exchange plans by settingincreased standards for coverage and grant the insurance commissioner broad author-

ity to reject plans with discriminatory benefits. Tis heightened level of authority allows

the state to better protect patients from discriminatory benefits before they come to the

market. Additionally, the state also took action to ensure that patients have adequate access

to providers, and that under certain conditions in-network costs apply to out-of-network

providers. Tis helps to ensure that patients receive timely and affordable treatment. Further,

Washington has several platinum plan choices, giving patients with significant health needs

a choice of plans with additional benefits and cost-sharing protections.

Montana, an FFE, established a new requirement to ensure that benefit designs

do not discriminate or impede access to care for patients. Specifically, the state

requires issuers to offer at least one silver, gold, and platinum exchange plan that usescopayments (rather than coinsurance) and that does not subject any drugs to the deductible,

including the specialty tier.

State efforts to prevent, identify, and mitigate potential discrimination can make a big

difference for patients with chronic conditions and disabilities, who rely on the protections

afforded by the ACA.

High-Performing Average-Performing Low-Performing



Tra nsparency

In states across the nation, patients have limited access to transparent, easy-to-understand,

complete information about the covered services and costs of exchange plans. Most exchange

websites, including HealthCare.gov, have links to plan materials, such as the formulary and

provider directory. Yet, linked resources are a challenge to navigate, particularly for patients

with complex conditions who need to compare the intricate details of plan coverage and costs.

In addition, some, but not all, exchanges include decision support tools, such as search tools

and out-of-pocket calculators, to help patients navigate different plan choices. While most

exchange websites have sort and filter functions, these features do not adequately assist

patients in selecting an appropriate plan. Across the country, very few states have taken

action to help increase transparency standards around covered services and costs of exchange

plans. Tis challenges patients as they are trying to make informed plan selections.

Maryland, an SBE, is trailblazing a path for transparency standards among

exchange plans. First, the state’s exchange website features one decision support

tool—a provider search engine – that helps patients chose a plan that includes their doctor.

Additionally, the state requires plan documents to include specific information. For example,

formularies must include the tier placement and cost sharing for each drug covered by the

plan. Also, when issuers file their plans with the state, the documentation must include a listof medicines covered under the plan’s medical benefit.

State Oversight

State oversight of exchange plans is critical to ensuring a patient-centered market. Some

states enhance the oversight of the plans offered on exchanges by negotiating with carriers

regarding the number of product offerings or requiring plans to offer more than silver and

gold metal level plans. Other states use the rate review process to ensure that plan premiums

reflect the benefits offered and that any increase in premium from year to year is justified.

In most instances, well-regulated insurance markets attract a healthy number of carriers

offering exchange plans, which increases competition and choice for patients. Tese types of

measures ensure that exchange plans meet applicable requirements and that the market is

competitive, allowing patients to have more options when selecting coverage.

Massachusetts, an SBE with the distinction of offering the first health insurance

exchange in the country, has long acted to ensure the state has effective oversight of

exchange plans. Te state is considered an active purchaser, meaning the exchange negotiates

with insurers, chooses which carriers can offer exchange plans, and sets criteria for partic-

ipating plans. For example, Massachusetts has twelve carriers in the exchange, and each of

these carriers is required to offer plans at all four metal levels, ensuring that patients have a

broad set of options from which to select a plan that best meets their needs.

Michigan, an FFE, also has taken notable steps to have adequate oversight of exchange

plans. Te state requires issuers to standardize offerings inside and outside of the

exchange, which unifies and stabilizes both markets and ensures that patients might be equally

served by plans in either market.

Uniformity

States have acted to make it easier for patients to compare exchange plans. Some SBEs

have standardized the benefit designs for plans at all metal levels—creating uniform

cost-sharing structures for all benefits across all plans at each metal level. Six SBEs—

California, Connecticut, Massachusetts, New York, Oregon, and Vermont—have stan-

dardized exchange plans in this way. Other states have taken less intensive approaches to

improve plan comparisons, either by establishing plan quality rating systems or by standard-

izing plan materials to follow a particular template.



California, an SBE, has led other states in its efforts to improve the comparabil-

ity of exchange plans. Key protections in the state include the standardized benefit

designs across all metal levels, including the cost-sharing reduction versions of silver plans

that are available to people with limited income. Te state does not allow any non-standard

plans in the exchange, which is unique among states with standardized plans. Tese require-

ments mean that all people enrolled in the same metal level plan in the state encounter the

same cost sharing for the same benefits; in effect, it levels the playing field. California hasimplemented a quality rating system that assigns plans up to four stars using the results of

consumer surveys. Finally, the state requires plans to update their formularies monthly and

is developing a standard template required for plan formularies, beginning in 2017.

Continuity of Care

Actions to ensure continuity-of-care between plans or types of coverage can help patients

maintain access during transition period. For example, when patients enroll in a new

exchange plan for the following plan year or when eligibility for Medicaid or subsidized

exchange coverage shifts, patients are at risk for problems accessing care during the change

in coverage. In fact, the Medicaid expansion is itself an opportunity for states to expand

coverage to low-income individuals who cannot qualify for exchange subsidies. Other states

offer enhanced premium subsidies beyond assistance offered from the federal governmentor established bridge plans to help individuals whose income is on the border between

Medicaid and subsidized exchange eligibility. Bridge plans are a type of health insurance

option for people whose eligibility for Medicaid and exchange coverage might shift from

year to year. Some states are creating these plans as a more stable option for patients to

ensure they have consistent access to coverage and care.

Delaware, an SPE, created transition periods for people whose eligibility for public

programs changes, including those moving from Medicaid into exchange plans. Te

requirements allow people to access prescriptions for 60 days and medical treatments for 90

days to ensure patients can maintain their treatment plans while changing plans or sources

of coverage.

Vermont, an SBE, funds cost-sharing reduction subsidies for a larger group ofexchange enrollees than the federally funded program. Te expanded population

includes individuals and families with income between 250% and 300% of the federal

poverty level, expanding the population of people who are eligible for this extra financial

assistance in the state.

Areas for Actions /

Following the first full year of exchanges, some states have emerged as leaders in imple-

menting patient-centered standards and reforms. However, there is more work left to do.

Given the challenges leading up to exchange implementation and the Medicaid expansion,

some states prioritized operational and technical readiness over patient-friendly tools andstandards. Now that HealthCare.gov and most SBE websites are operating effectively, it is

important for states to begin to turn their attention to ensuring that all people have access

to coverage and care that meets their needs.

Opportunities exist for patient advocates to work with states to improve the patient-friend-

liness of their insurance markets in the coming years. NHC partners may consider the

following three issues as they develop their advocacy plans for the 2016 and 2017 plan years.



State and Federal Considerations /

Tese reports identify states creating some of the nation’s most patient-friendly insurance

markets as leaders that can help to pave the way for other states. At the same time, they

also uncover some key areas for improvement to make the exchanges truly patient centered.

ogether with advocacy groups and aligned partners, states can use their performance

across the metrics as starting points to begin to move exchange markets in favor of helpingpatients access better and more affordable care. Troughout the course of advocacy efforts,

one must be mindful of the following points:

Understand the State Audience

Advocates can leverage their insight into the state’s dynamic to target the right audience

with the applicable message at the appropriate time. Some of the metrics identified in these

reports represent approaches to insurance markets on which both sides of the political

spectrum can agree (i.e. transparency). Tese types of less contentious, bipartisan policies

are good starting points for some states looking to secure new protections for patients.

Other states with a more active legislative or regulatory history on exchanges might be good

targets for more complex patient-centered measures, such as standardized benefit designs,

supplemental premium subsidies, or cost-sharing caps.

Consider the Federal Government

Members and partners also should consider the role the federal government plays to estab-

lish standards for many of these priority areas. Current federal standards are quite limited in

their patient centeredness, offering significant opportunity to make adjustments that would

lead to enhanced patient protections for many, or even all, states. With so many states using

HealthCare.gov and following other federal standards, national requirements may offer

substantial influence over markets across multiple states in the near term.

Moving Forward /

Te National Health Council is dedicated to ensuring that the ACA achieves its objectives

of high quality and affordable care for all people, including those with chronic diseases anddisabilities. Understanding the landscape of patient-centeredness across all states can begin

conversations that lead to positive changes for patients in these markets. Te NHC will

continue to work with members and partners as they engage with states and the federal

government to ensure the exchange markets offer the most equitable, affordable, and highest

quality coverage and care possible for patients.



Increase State Oversight and Regulat ion of Exchange Markets

Currently, most states rely upon limited federal guidance for the methods they should use to

ensure that exchange markets are not discriminatory. Few states have taken steps to further

define their plan reviews and oversight activities. Most SBEs are not actively negotiating

with plans to participate in the exchange. And, though most states have an effective rate

review process, additional standards in this area can further influence premium rates among

exchange plans. Finally, most SBEs have not set contracting standards for participation inthe exchange, such as requiring that the issuers offer plans across all metal levels. Tese types

of oversight actions can help to ensure that patients can access appropriate and affordable

choices in the exchanges.

Support Implementation of Robust Quality Rating Systems in All Exchanges

Te SBEs of Connecticut, Hawaii, Idaho, Kentucky, and Vermont have not yet released

information about their quality rating systems. SBEs have the option to implement their

own standards by 2017 or to follow the federal approach. For FFEs, public reporting of

quality ratings and enrollee satisfaction will occur for the 2017 open enrollment period.

NHC partners have the opportunity to work with states and the federal government to

encourage rating systems that measure the experience of patients in plans and also appropri-

ately reward plans for focusing on patient-centered care.

Ensure Medicaid Changes and Expansions OfferProtections Afforded under the Tradit ional Program

A state’s approach to Medicaid expansion should ensure that patients have increased

access to coverage and care, while preserving the patient protections guaranteed under

the program. In 21 states, Medicaid has not been expanded to individuals and families

with incomes below 138% of the federal poverty level, leaving many patients without any

access to affordable health coverage. Another six states used waivers to allow the state

to enroll eligible individuals and families into exchange plans rather than traditional

Medicaid. Tough these waivers do expand access to coverage, advocates and states should

work together to ensure that Medicaid enrollees in these states have the full protections

afforded under traditional Medicaid. Advan ce Patient Tools that Improve Transpa rency

ools that increase transparency into the coverage and costs of exchange

plans or offer decision support mechanisms can improve the plan selec-

tion process for people shopping for coverage in exchange plans.

Te cost to develop effective decision support tools may be prohibitive

to many SBEs, and some states may to need to rely on federal tools,

when and if they are developed.

A more attainable option for many states might be requirements

that improve the transparency of plan information. Te NHC’s recent

survey indicated that most patients felt they did not have all the

information they needed to choose a health plan. Further, 36% ofexchange enrollees had a hard time finding a list of providers and 38%

had difficulty accessing plan formularies.2 Even without large-scale,

decision support tools, states can make small improvements to

transparency standards that go a long way to helping people enroll in

plans that meet their health and budget needs.

76%

24%

63%

37%

58%

42%

Bronze Silver Gold

Had NeededInformation

Did Not Have NeededInformation

Figure 1. Share of Respondents Who

Reported Having “All the Information They

Needed” When Choosing a Health Plan

2 Navigating the ACA among Enrollees with Chronic Illnesses,” Celinda Lake, March 2015.



State-by-State

Patient-Centeredness Data



A l a b a m a

A l a s

k a

A r i z o n a

A r k a n s a s

C a

l i f o r n

i a

C o

l o r a

d o

C o n n e c

t i c u

t

D e

l a w a r e

D i s t r i c t o

f C o

l u m

b i a

F l o r i

d a

G e o r g

i a

H a w a

i i

I d a

h o

I l l i n o

i s

I n d i a n a

I o w a

K a n s a s

N O N D I S C R I M I N A T I O N

State Action toLimit Discrimination

Number of PlatinumPlans Available

Provider NetworkRequirements

Silver PlanPremium Stability

OverallNondiscriminationPerformance

T R A N S P A R E

N C Y

Exchange WebsiteDecision SupportTools and Information

Plan MaterialTransparencyRequirements

Overall TransparencyPerformance

S T A T

E O V E R S I G H T

Purchasing Type

State ExchangeOversightRequirements

Effective Rate

Review

Number of Carriersin the 2015 Market

Overall State Over-sight Performance

U N I F O R M I T Y

Standardized BenefitDesigns

Quality RatingSystem

Standardized Displayof Information

Overall UniformityPerformance

C O N T I N U I T Y O F C A R E Continuity of Care

Requirements

Medicaid Expansion

Overall Continuity ofCare Performance

Beneficial for Patients

Neutral for Patients

Negative for Patients

High-Performing

Average-Performing

Low-Performing



K e n

t u c

k y

L o u

i s i a n a

M a

i n e

M a r y

l a n

d

M a s s a c

h u s e

t t s

M i c h i g a n

M i n n e s o

t a

M i s s

i s s

i p p

i

M i s s o u r i

M o n

t a n a

N e

b r a s

k a

N e v a

d a

N e w

H a m p s

h i r e

N e w

J e r s e y

N e w

M e x

i c o

N e w

Y o r k

N o r t

h C a r o

l i n a







T R A N S P A R E

N C Y




S T A T

E O V E R S I G H T

Purchasing Type


Effective Rate

Review



U N I F O R M I T Y






Requirements

Medicaid Expansion





High-Performing

Average-Performing

Low-Performing



N o r t

h D a

k o

t a

O h i o

O k l a h o m a

O r e g o n

P e n n s y

l v a n

i a

R h o

d e

I s l a n

d

S o u

t h C a r o

l i n a

S o u

t h D a

k o

t a

T e n n e s s e e

T e x a s

U t a h

V e r m o n

t

V i r g

i n i a

W a s

h i n g

t o n

W e s

t V i r g

i n i a

W i s c o n s

i n

W y o m

i n g







T R A N S P A R E

N C Y




S T A T

E O V E R S I G H T

Purchasing Type


Effective Rate

Review



U N I F O R M I T Y






Requirements

Medicaid Expansion





High-Performing

Average-Performing

Low-Performing


14/11814 · STATE PROGRESS REPORT

State-by-State

Progress Reports

State Actions Protecting Patients in the Exchange


15/118STATE PROGRESS REPORT · 15

STATE ACTIONS PROTECTING PATIENTS IN THE EXCHANGE

FIVE PATIENT-FOCUSED PRINCIPLES

NON-DISCRIMINATION

To ensure cost sharing and other plan designs do not discriminate or impedeaccess to care.

No state action to limit discrimination. Four unique platinum oerings in the 2015 exchange.

No state action on provider network requirements.

The premium for the 2nd lowest cost silver plan is 3% higher in 2015 than itwas in 2014.2

For non-discrimination metrics, relative to other states, Alabama is an

Average-Performing State

TRANSPARENCY

To promote better consumer access to information about covered services andcosts in exchange plans.

HealthCare.gov links to external provider networks and formularies andalso allows consumers to lter search results. However, the website lacks aformulary search tool, a provider search tool, and calculators to help estimatetax credit or out-of-pocket expense amounts.

No state action regarding contracting requirements for plan informationtransparency.

For transparency metrics, relative to other states, Alabama is a

Low-Performing State

ALABAMA HIGHLIGHTS

Alabama’s exchange is regulated by

the federal government and operates

through HealthCare.gov.

In the 2014 plan year, 97,900

Alabamians selected an exchange planthrough HealthCare.gov. About 22%

of Alabama residents who are eligible

for exchange coverage enrolled in an

exchange plan in 2014.1

Alabama has not expanded Medicaid.

PROGRESS LEGEND

This report measures states using two

methods of evaluation:

First, the report measures a state’s

performance on a series of metrics

related to the ve principles.



Benecial for Patients

Second, the report compares a state’s

aggregate performance on all metrics

within each principle to other states

performance on these same metrics.

Average-Performing

High-Performing

Low-Performing

Alabama Progress Report

OVERVIEW

States vary in terms of the patient-centeredness of their health insurance markets. While federal rules set minimum

requirements for consumer protections, some states have acted to make their markets more patient-focused. Thisscorecard evaluates states based on ve key areas that assess patient-friendliness of their insurance markets topromote policies that best protect patients.



STATE OVERSIGHT

To ensure all health insurance exchange plans meet applicable requirements.

Passive purchasing—the state does not actively negotiate with plans toparticipate in the exchange.

No state action regarding contracting requirements for exchange participation.

Alabama does not have an eective rate review program.3

Three carriers in the 2015 exchange market.

For state-oversight metrics, relative to other states, Alabama is a


UNIFORMITY

To create standards to make it easier for patients to understand and compareexchange plans.

No state action to standardize benet designs.

The quality rating system planned by the federal government for use onHealthCare.gov will show ratings for the 2017 plan year.

No state action on standardized display of plan information.

For uniformity metrics, relative to other states, Alabama is an


CONTINUITY OF CARE

To broaden sources of coverage and protect patients transitioning between plans.

No state action on continuity-of-care requirements.4

Alabama has not expanded Medicaid, which would provide coverage for anestimated 272,000 people in the state.5

For continuity-of-care metrics, relative to other states, Alabama is a


METHODOLOGY

Data by Avalere Health as of January 1, 2015. Avalere maintains a proprietary database of state policy developments for all 50 states and DC Avalere also used key resources from publicly available websites, ci ted where applicable. Avalere conducted a focused review of state exchangeinsurance markets; this assessment is not intended to be a comprehensive review of state insurance markets. Avalere only included nalizedactions established in the state, and did not include proposed measures or actions.

For denitions of key terms, see the National Health Council’s Putting Patients First® glossary.

1 Kaiser Family Foundation, “Estimated Number of Individuals Eligible for Financial Assistance through the Marketplaces,” November, 2014, accessed via:http://k.org/other/state-indicatoestimated-number-of-individuals-eligible-for-premium-tax-credits-through-the-marketplaces/ 2 Kaiser Family Foundation, “Analysis of 2015 Premium Changes in the Aordable Care Act’s Health Insurance Marketplaces,” January 06, 2015, accessed via: http://k.org/health-reform

issue-brief/analysis-of-2015-premium-changes-in-the-aordable-care-acts-health-insurance-marketplaces/ 3 The Center for Consumer Information & Insurance Oversight, “State Eective Rate Review Programs,” April 16, 2014, accessed via: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and

FAQs/rate_review_fact_sheet.html

4 Families USA, “Standards for Health Insurance Provider Networks: Examples from the States,” November 2014, accessed via:http://familiesusa.org/sites/default/les/product_document ACT_Netwo rk%20Adeq uacy%20Bri ef_nal_web.pd f

5 Kaiser Family Foundation, “A Closer Look at the Impact of State Decisions Not to Expand Medicaid Coverage for Uninsured Adults,” April 24, 2014, accessed via:http://k.org/medicaidfact-sheet/a-closer-look-at-the-impact-of-state-decisions-not-to-expand-medicaid-on-coverage-for-uninsured-adults/

A MORE PATIENT-FOCUSED

ALABAMA MARKETPLACE

Alabama has not exercised its ful

authority to regulate the exchangeto promote patient protections

Alabama’s reliance on the federa

government to run the exchange

reduces the state’s inuence oveits own health insurance market

Alabama would have more contro

over exchange plans if the state

opted to create a state-based

exchange or, as an intermediary

step, a partnership or exchange

plan management model. Alabama

has yet to establish standards

that would increase transparency

or uniformity, protect patients

from discrimination, or develop

continuity-of-care requirements

to help patients maintainaccess to care. Under a dierent

operational model, Alabama also

could become an active purchaser

which could help the state bette

manage increasing premiums.

Another critical step towards a

patient-friendly health insurance

market would be for Alabama to

expand Medicaid. Expansion of

Medicaid would provide health

insurance for more than 272,000

Alabamians.



NON-DISCRIMINATION


Alaska enacted legislation requiring issuers to notify members at least 90days before implementing cost sharing, deductibles, and copayments forcertain categories of drugs (e.g., specialty medications) that exceed thosefor non-preferred brand drugs.

Alaska has no platinum oerings in the 2015 exchange.


The premium for the 2nd lowest cost silver plan is 28% higher in 2015 thanit was in 2014.2 PROGRESS LEGEND










Alaska Progress ReportSTATE ACTIONS PROTECTING PATIENTS IN THE EXCHANGE


Average-Performing

High-Performing

Low-Performing




OVERVIEW



ALASKA HIGHLIGHTS

Alaska’s exchange is regulated by



In the 2014 plan year, 12,900 Alaskans

selected an exchange plan throughHealthCare.gov. About 15% of

Alaska residents who are eligible fo

exchange coverage enrolled in an


Alaska has not expanded Medicaid.

For non-discrimination metrics, relative to other states, Alaska is a

TRANSPARENCY




For transparency metrics, relative to other states, Alaska is a





1

2

3

4

5

STATE OVERSIGHT




Its eective rate review program allows the state to manage premium

increases.3

Two carriers in the 2015 exchange market.

Kaiser Family Foundation, “Estimated Number of Individuals Eligible for Financial Assistance through the Marketplaces,” November, 2014, accessed via: http://k.org/other/state-indicator/estimated-number-of-individuals-eligible-for-premium-tax-credits-through-the-marketplaces/ Kaiser Family Foundation, “Analysis of 2015 Premium Changes in the Aordable Care Act’s Health Insurance Marketplaces,” January 06, 2015, accessed via: http://k.org/health-reform/issue-brief/analysis-of-2015-premium-changes-in-the-aordable-care-acts-health-insurance-marketplaces/The Center for Consumer Information & Insurance Oversight, “State Eective Rate Review Programs,” April 16, 2014, accessed via: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/rate_review_fact_sheet.html

Families USA, “Standards for Health Insurance Provider Networks: Examples from the States,” November 2014, accessed via: http://familiesusa.org/sites/default/les/product_documents/ACT_Network%20Adequacy%20Brief_nal_web.pdfKaiser Family Foundation, “A Closer Look at the Impact of State Decisions Not to Expand Medicaid Coverage for Uninsured Adults,” April 24, 2014, accessed via: http://k.org/medicaidfact-sheet/a-closer-look-at-the-impact-of-state-decisions-not-to-expand-medicaid-on-coverage-for-uninsured-adults/

METHODOLOGY




ALASKA MARKETPLACE

Alaska has not exercised its ful

authority to regulate the exchangeto promote patient protections

Alaska’s reliance on the federa


reduces the state’s influenceover its own health insurance

market. Alaska would have more

control over exchange plans if

the state opted to create a state-

based exchange or a partnership

exchange. Alaska has yet to

establish exchange standards




continuity-of-care requirements. In

addition, Alaska’s exchange does

not foster competition as there areonly two carriers oering coverage As a result, there are no platinum

plans oered in the state, limiting

options for the people who would

benet most—those with chronic

conditions and disabilities. Unde

a different operational model

Alaska also could become an

active purchaser, which could help

the state better manage increasing

premiums. Another critical step

towards a patient-friendly health

insurance market would be fo Alaska to expand Medicaid

Expansion of Medicaid would

provide health insurance for more

than 30,000 Alaskans.

For state-oversight metrics, relative to other states, Alaska is an

For uniformity metrics, relative to other states, Alaska is an

For continutity-of-care metrics, relative to other states, Alaska is a

UNIFORMITY

To create standards to make it easier for patients to understand and compare

exchange plans.




CONTINUITY OF CARE



Alaska has not expanded Medicaid, which would provide coverage for anestimated 30,000 people in the state.5






NON-DISCRIMINATION


No state action to limit discrimination.Seventeen unique platinum oerings in the 2015 exchange.


The premium for the 2nd lowest cost silver plan is 10% lower in 2015 than itwas in 2014.2

PROGRESS LEGEND









performance on these same metrics

Arizona Progress ReportSTATE ACTIONS PROTECTING PATIENTS IN THE EXCHANGE


Average-Performing

High-Performing

Low-Performing




OVERVIEW



ARIZONA HIGHLIGHTS

Arizona’s exchange is regulated by




Arizonans selected an exchange planthrough HealthCare.gov. About 19%of Arizona residents who are eligible

for exchange coverage enrolled in anexchange plan in 2014.1

Arizona expanded Medicaid, eectiveJanuary 1, 2014.

For non-discrimination metrics, relative to other states, Arizona is an

TRANSPARENCY




For transparency metrics, relative to other states, Arizona is a





1

2

3

4

STATE OVERSIGHT





increases.3

Eleven carriers in the 2015 exchange market.

Kaiser Family Foundation, “Estimated Number of Individuals Eligible for Financial Assistance through the Marketplaces,” November, 2014, accessed via: http://k.org/other/state-indicator/estimated-number-of-individuals-eligible-for-premium-tax-credits-through-the-marketplaces/ Kaiser Family Foundation, “Analysis of 2015 Premium Changes in the Aordable Care Act’s Health Insurance Marketplaces,” January 06, 2015, accessed via: http://k.org/health-reform/issue-brief/analysis-of-2015-premium-changes-in-the-aordable-care-acts-health-insurance-marketplaces/The Center for Consumer Information & Insurance Oversight, “State Eective Rate Review Programs,” April 16, 2014, accessed via: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/rate_review_fact_sheet.html

Families USA, “Standards for Health Insurance Provider Networks: Examples from the States,” November 2014, accessed via: http://familiesusa.org/sites/default/les/product_documents/ACT_Network%20Adequacy%20Brief_nal_web.pdf

METHODOLOGY

Data by Avalere Health as of January 1, 2015. Avalere maintains a proprietary database of state policy developments for all 50 states and DC Avalere also used key resources from publicly available websites, ci ted where applicable. Avalere conducted a focused review of state exchangeinsurance markets; this assessment is not intended to be a comprehensive review of state insurance markets. Avalere only included nalized

actions established in the state, and did not include proposed measures or actions.For denitions of key terms, see the National Health Council’s Putting Patients First® glossary.


ARIZONA MARKETPLACE

Arizona has not exercised its fulauthority to regulate the exchangeto promote patient protections

Arizona’s reliance on the federa


reduces the state’s inuence overits own health insurance market

Arizona would have more contro

over exchange plans if the state

opted to create a state-based

exchange or, as an intermediary

step, a partnership or exchange

plan management model. Arizona

has yet to establish standards




continuity-of-care requirements to

help patients maintain access tocare. Under a dierent operationamodel, Arizona also could become

an active purchaser.

For state-oversight metrics, relative to other states, Arizona is an

For uniformity metrics, relative to other states, Arizona is an

For continutity-of-care metrics, relative to other states, Arizona is an

UNIFORMITY


exchange plans.




CONTINUITY OF CARE



Arizona expanded Medicaid, which now covers an estimated 299,000 peoplein the state.








NON-DISCRIMINATION


No state action to limit discrimination.No unique platinum oerings in the 2015 exchange.

Arkansas enacted legislation requiring exchange plans to meet speciedminimum network adequacy standards for primary care doctors, essentialcommunity providers, and specialists.


For non-discrimination metrics, relative to other states, Arkansas is an


TRANSPARENCY




For transparency metrics, relative to other states, Arkansas is a


ARKANSAS HIGHLIGHTS

Arkansas established a state-federa

partnership exchange. The state

is responsible for managing plan

participation and customer assistance

in the exchange. Arkansas residents

use the federal exchange, HealthCaregov, to compare and purchase

coverage.

In the 2014 plan year, 43,400 Arkansansselected an exchange plan through

HealthCare.gov. About 17% of Arkansasresidents who are eligible for exchangecoverage enrolled in an exchange plan

in 2014.1

Arkansas expanded Medicaid, eectivein 2014.

PROGRESS LEGEND













Average-Performing

High-Performing

Low-Performing

Arkansas Progress Report

OVERVIEW





STATE OVERSIGHT





increases.3

Four carriers in the 2015 exchange.

For state-oversight metrics, relative to other states, Arkansas is an


UNIFORMITY

To create standards to make it easier for patients to understand and compareexchange plans.




For uniformity metrics, relative to other states, Arkansas is an


CONTINUITY OF CARE



Arkansas has expanded Medicaid under a premium assistance model, which

now covers an estimated 75,000 people in the state.

For continuity-of-care metrics, relative to other states, Arkansas is an


METHODOLOGY


For denitions of key terms, see the National Health Council’s Putting Patients First®

glossary.

1 Kaiser Family Foundation, “Estimated Number of Individuals Eligible for Financial Assistance through the Marketplaces,” November, 2014, accessed via:http://k.org/other/state-indicatoestimated-number-of-individuals-eligible-for-premium-tax-credits-through-the-marketplaces/

2 Kaiser Family Foundation, “Analysis of 2015 Premium Changes in the Aordable Care Act’s Health Insurance Marketplaces,” January 06, 2015, accessed via: http://k.org/health-reformissue-brief/analysis-of-2015-premium-changes-in-the-aordable-care-acts-health-insurance-marketplaces/

3 The Center for Consumer Information & Insurance Oversight, “State Eective Rate Review Programs,” April 16, 2014, accessed via: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-andFAQs/rate_review_fact_sheet.html

4 Families USA, “Standards for Health Insurance Provider Networks: Examples from the States,” November 2014, accessed via:http://familiesusa.org/sites/default/les/product_document ACT_Netwo rk%20Adeq uacy%20Bri ef_nal_web.pd f

5 The Governor signed legislation delaying the state’s plans to establish a state-based exchange until the Supreme Court rules on the legality of subsidies in federally-facilitated exchanges


ARKANSAS MARKETPLACE

Arkansas’ partial reliance on the

federal government to run the

exchange reduces the state’s

influence over its own health

insurance market. Arkansas would

have more control over exchangeplans if the state opted to create

a state-based exchange; currentlythe state intends to run its own

SHOP exchange in 2016 and its

individual exchange in 2017.5

Arkansas has yet to establish

standards that would increase

transparency or uniformity, protect

patients from discrimination

or develop continuity-of-care

requirements to help patients

maintain access to care. Unde

a different operational model Arkansas also could become an

active purchaser to have more

authority over plan participation

Further, the state has no platinum

plans, which limits options for the

people who would benet most—

those with chronic conditions

and disabilities. Contracting

requirements could encourage

or potentially require, carriers

to offer a platinum plan. As

Arkansas implements the premium

assistance model, the state shouldensure the model preserves patient

protections inherent in Medicaid.



TRANSPARENCY

To promote better consumer access to information about covered servicesand costs in exchange plans.

California’s website oers a cost calculator to help consumers estimate theirannual medical spending for each plan oering. The enrollment portal allowsconsumers to lter plan options and has links to plans’ provider directoriesand formularies. However, the website lacks formulary and provider searchtools.


NON-DISCRIMINATION


California prohibits issuers from altering product benet design fromcopayment to coinsurance or vice versa, or shifting product types (e.g.,PPO, HMO).

Sixteen unique platinum plans in the 2015 exchange.

California enacted legislation increasing provider network adequacy andtimely access to care, and prohibited plans from narrowing networks beyondnormal network churn.


CALIFORNIA HIGHLIGHTS

California established a state-based

exchange, called Covered California

In the 2014 plan year, 1.2 million

Californians selected an exchange

plan through Covered California About 37% of California residents whoare eligible for exchange coverage

enrolled in an exchange plan in 2014.

California expanded Medicaid

eective January 1, 2014.

PROGRESS LEGEND












Average-Performing

High-Performing

Low-Performing





For transparency metrics, relative to other states, California is an

California Progress Report

For non-discrimination metrics, relative to other states, California is a

High-Performing State

OVERVIEW


requirements for consumer protections, some states have taken extra steps to make their markets more patient-focused. This Progress Report measures a state across ve principles to assess how well its insurance market isdesigned to meet the needs of people with chronic diseases and disabilities.



UNIFORMITY


exchange plans.

California standardized benet designs.

California rates exchange plans using a four-star quality rating system,derived from consumer survey results.

California requires issuers to provide formularies online and update theinformation monthly. The state is developing a standard formulary templatethat will be implemented by January 1, 2017.

STATE OVERSIGHT


Active purchasing—the state actively negotiates with plans to participatein the exchange.

California requires multi-year contracts, limits the number of bids submittedby issuers, and requires plans to oer products in specic metals levels,including catastrophic plans.

Its eective rate review program allows the state to manage premiumincreases.3

Eleven carriers in the 2015 exchange.

CONTINUITY OF CARE

To broaden sources of coverage and protect patients transitioning between

plans.

California is awaiting approval to implement Bridge Plans, which aim toreduce the eects of churn between Medicaid and the exchange. The statealso requires managed care plans to allow enrollees to continue seeingproviders who have left their plan’s network per the enrollee’s request, forselect conditions or services in a specic time frame.4

California expanded Medicaid, which now covers an estimated 2,343,000people in the state.


CALIFORNIA MARKETPLACE

Cal i fo rn ia has ach ieved

considerable success in fostering

a patient-focused market, as

they have taken numerous state

actions, beyond the federa

requirements, that better protectpatients.

However, California has not

exercised its full authority to

regulate the exchange to promotepatient protections. Notably, the

state could enact contracting

requirements to enhance plan

information transparency. Though

Covered California has an out-of-

pocket calculator, it is limited in

its ability to accurately assess

estimated costs for patients. Inorder to best protect patients

California should develop a more

robust and precise tool.


For state-oversight metrics, relative to other states, California is a


For uniformity metrics, relative to other states, California is a


For continuity-of-care metrics, relative to other states, California is a

1

2

3

4

Kaiser Family Foundation, “Estimated Number of Individuals Eligible for Financial Assistance through the Marketplaces,” November, 2014, accessed via: http://k.org/other/state-indicator/estimated-number-of-individuals-eligible-for-premium-tax-credits-through-the-marketplaces/ Kaiser Family Foundation, “Analysis of 2015 Premium Changes in the Aordable Care Act’s Health Insurance Marketplaces,” January 06, 2015, accessed via: http://k.org/health-reform/issue-brief/analysis-of-2015-premium-changes-in-the-aordable-care-acts-health-insurance-marketplaces/ The Center for Consumer Information & Insurance Oversight, “State Eective Rate Review Programs,” April 16, 2014, accessed via: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/rate_review_fact_sheet.html


METHODOLOGY





COLORADO HIGHLIGHTS

Colorado established a state-based

exchange, called Connect for Health

Colorado.


Coloradans selected an exchange planthrough Connect for Health Colorado About 25% of Colorado residents whoare eligible for exchange coverage

enrolled in an exchange plan in 2014.

Colorado expanded Medicaid


PROGRESS LEGEND










Colorado Progress ReportSTATE ACTIONS PROTECTING PATIENTS IN THE EXCHANGE


NON-DISCRIMINATION


No state action to limit discrimination. Two unique platinum plans in the 2015 exchange.

Colorado mandates that managed care plans have a provider network that issucient in numbers and types of providers to ensure timely access to care.


For non-discrimination metrics, relative to other states, Colorado is an

TRANSPARENCY


Colorado’s website has a formulary search tool to show whether eachavailable plan covers specic drugs. The site has a provider search tool,a calculator to estimate tax credit amounts, access to plans’ providerdirectories and formularies, as well as lters for search results.


Average-Performing


High-Performing

Low-Performing




OVERVIEW

States vary in terms of the patient-centeredness of their health insurance markets. While federal rules set

minimum requirements for consumer protections, some states have taken extra steps to make their marketsmore patient-focused. This Progress Report measures a state across ve principles to assess how well itsinsurance market is designed to meet the needs of people with chronic diseases and disabilities.

For transparency metrics, relative to other states, Colorado is an




1

2

3

4

For state-oversight metrics, relative to other states, Colorado is an

For uniformity metrics, relative to other states, Colorado is an

For continutity-of-care metrics, relative to other states, Colorado is an

STATE OVERSIGHT





increases.3

Twelve carriers in the 2015 exchange.

UNIFORMITY


exchange plans.


Colorado rates exchange plans using a ve-star quality score based customersurveys as well as clinical measures.


CONTINUITY OF CARE


plans.


Colorado expanded Medicaid, which now covers an estimated 351,000people in the state.


COLORADO MARKETPLACE

Co lo rado has ach ieved

considerable success in fostering

a patient-focused market, as

they have taken numerous state

actions, beyond the federa

requirements, that better protectpatients.

However, Colorado has not


regulate the exchange to promotepatient protections. Through

legislative or other state action

Colorado could standardize

benet designs and plan benet

materials. The state also could

consider oversight activities that

would screen exchange plans fo

discrimination. The state has veryfew platinum plans, which limits

options for the people who would

benet most—those with chronicconditions and disabil it ies

Contracting requirements could

encourage, or potentially require

carriers to offer a platinum

plan. Since it is a state-based

exchange, Colorado could exert

even more influence over the

exchange by becoming an activepurchaser.




Kaiser Family Foundation, “Estimated Number of Individuals Eligible for Financial Assistance through the Marketplaces,” November, 2014, accessed via: http://k.org/other/state-indicator/estimated-number-of-individuals-eligible-for-premium-tax-credits-through-the-marketplaces/ Kaiser Family Foundation, “Analysis of 2015 Premium Changes in the Aordable Care Act’s Health Insurance Marketplaces,” January 06, 2015, accessed via: http://k.org/health-reform/issue-brief/analysis-of-2015-premium-changes-in-the-aordable-care-acts-health-insurance-marketplaces/ The Center for Consumer Information & Insurance Oversight, “State Eective Rate Review Programs,” April 16, 2014, accessed via: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/rate_review_fact_sheet.html Families USA, “Standards for Health Insurance Provider Networks: Examples from the States,” November 2014, accessed via: http://familiesusa.org/sites/default/les/product_documents/ACT_Network%20Adequacy%20Brief_nal_web.pdf

METHODOLOGY

Data by Avalere Health as of January 1, 2015. Avalere maintains a proprietary database of state policy developments for all 50 states and DC Avalere also used key resources from publicly available websites, ci ted where applicable. Avalere conducted a focused review of state exchangeinsurance markets; this assessment is not intended to be a comprehensive review of state insurance markets. Avalere only included nalized

actions established in the state, and did not include proposed measures or actions.For denitions of key terms, see the National Health Council’s Putting Patients First® glossary.



NON-DISCRIMINATION


No state action to limit discrimination.One unique platinum plan in the 2015 exchange.

Connecticut requires exchange plans to have a provider network that issucient in numbers to ensure timely access to care.


CONNECTICUT HIGHLIGHTS

Connecticut established a state

based exchange, called Access

Health CT.


Connecticut residents selectedan exchange plan through Access

Health CT. About 33% of Connecticut

residents who are eligible for

exchange coverage enrolled in an


Connecticut expanded Medicaid


PROGRESS LEGEND












For non-discrimination metrics, relative to other states, Connecticut is an

TRANSPARENCY


The website allows consumers to lter plan oerings and has links to providerdirectories and formularies. The website lacks formulary and provider searchtools and calculators to help estimate tax credit or out-of-pocket expenseamounts.


Average-Performing

High-Performing

Low-Performing




For transparency metrics, relative to other states, Connecticut is a

Connecticut Progress Report



OVERVIEW


requirements for consumer protections, some states have taken extra steps to make their markets more patient-focused. This Progress Report measures a state across ve principles to assess how well its insurance market isdesigned to meet the needs of people with chronic diseases and disabilities.



CONTINUITY OF CARE


plans.


Connecticut expanded Medicaid.

STATE OVERSIGHT


Active purchasing—the state actively negotiates with plans to participate inthe exchange.

Connecticut requires multi-year contracts, limits the number of bids submittedby issuers, requires plans to oer products in specic metals levels, andrequires plans by a single issuer to have distinct dierences.

Its eective rate review program allows the state to manage premiumincreases.3

Six carriers in the 2015 exchange.

For state-oversight metrics, relative to other states, Connecticut is a

UNIFORMITY


exchange plans.

Connecticut standardized benet designs.Connecticut rates exchange plans using a four-star quality rating systembased on measures from the National Committee for Quality Assurance.



CONNECTICUT MARKETPLACE

Connecticut has achieved some

success in fostering a patient-

focused market, as they have

taken several state actions

beyond the federal requirements

that better protect patients.

However, Connecticut has not


regulate the exchange to promotepatient protections. Through

legislative or other state action

Connecticut could standardize

plan benefit materials and

enhance transparency of plan

documents. Patients would also

benet from the development o

an out-of-pocket calculator to

estimate health expenses andbetter inform plan selection.

The state has very few platinum

plans, which limits options for the

people who would benet most—those with chronic conditions and

disabilities. Additional contracting

requirements could encourage

or potentially require, carriers to

oer a platinum plan.

Finally, Connecticut could take

actions to establish continuity-of-care requirements to help patientsmaintain access to care.

For uniformity metrics, relative to other states, Connecticut is an



1

2

3

4

Kaiser Family Foundation, “Estimated Number of Individuals Eligible for Financial Assistance through the Marketplaces,” November, 2014, accessed via: http://k.org/other/state-indicator/estimated-number-of-individuals-eligible-for-premium-tax-credits-through-the-marketplaces/ Kaiser Family Foundation, “Analysis of 2015 Premium Changes in the Aordable Care Act’s Health Insurance Marketplaces,” January 06, 2015, accessed via: http://k.org/health-reform/issue-brief/analysis-of-2015-premium-changes-in-the-aordable-care-acts-health-insurance-marketplaces/ The Center for Consumer Information & Insurance Oversight, “State Eective Rate Review Programs,” April 16, 2014, accessed via: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/rate_review_fact_sheet.html


METHODOLOGY




For continuity-of-care metrics, relative to other states, Michigan is an





NON-DISCRIMINATION


Delaware enacted legislation capping patient cost sharing for specialty tierdrugs. The legislation also prohibits issuers from placing all drugs in a givenclass of drugs on a specialty tier.

One unique platinum plan in the 2015 exchange.

Delaware mandates that all plans sold in the exchange must have at leastone full-time equivalent primary care provider for every 2,000 patients.


For non-discrimination metrics, relative to other states, Delaware is an


TRANSPARENCY




For transparency metrics, relative to other states, Delaware is a


DELAWARE HIGHLIGHTS

Delaware established a state-federa

partnership exchange. The state

is responsible for managing plan

participation and customer assistance

in the exchange. Delaware residents

use the federal exchange, HealthCaregov, to compare and purchase

coverage.


Delawareans selected an exchange

plan through HealthCare.gov. About

29% of Delaware residents who are

eligible for exchange coverage enrolledin an exchange plan in 2014.1

Delaware expanded Medicaid, eectiv

enhancing the patient-centeredness of state health insurance markets

Documents