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1 Supporting Informed Decision-Maing in the Health Insurance Maretplace: A Progress Report FEBRUARY 2015

2 Contents 1 Executive Summary 4 Introduction 6 Methodology-In-Brief 7 Open Enrollment 2015: Consumer Access to Health Plan Information and Decision-Maing Tools Enhanced Anonymous Browsing Direct Access to Key Plan Features Useful Plan Display and Availability of Consumer Tools Easy Website Navigation and Lins for Assistance 17 Conclusion 19 Tables 21 Appendix A Methodology 25 Appendix B Subject Matter Expert Interviewees 26 Endnotes About the National Partnership for Women & Families At the National Partnership for Women & Families, we believe that actions spea louder than words, and for more than four decades we have fought for every major policy advance that has helped women and families. Today, we promote fairness in the worplace, reproductive health and rights, access to quality, affordable health care, and policies that help women and men meet the dual demands of their jobs and families. Our goal is to create a society that is fair and just, where nobody has to experience discrimination, all worplaces are family friendly, and no family is without quality, affordable health care and real economic security. Founded in 1971 as the Women s Legal Defense Fund, the National Partnership for Women & Families is a nonprofit, nonpartisan 501(c)3 organization located in Washington, D.C National Partnership for Women & Families. All rights reserved.

3 Supporting Informed Decision-Maing in the Health Insurance Maretplace: A Progress Report FEBRUARY 2015 Executive Summary A ey goal of the Affordable Care Act (ACA) was to create an insurance maret in which consumers would have the ability to compare coverage options across standardized criteria and identify the plan that best meets their families health care needs. As implementation of the ACA continues and the second open enrollment period comes to a close, the focus on consumer behavior and decision-maing is growing. A ey question for both advocates and policymaers is whether consumers have the tools they need to support informed choice with regard to health plan selection in the maretplace, since selecting the right plan one that meets a family s health care needs and preferences and aligns with its financial reality is ey to consumer satisfaction. This report loos at how well the maretplace, composed of the Federally-facilitated maretplace (Healthcare.gov) and 14 state-run maretplaces, is providing consumers with ey information about available health plans. 1 The report also assesses new tools and promising practices that maretplace websites are employing to enhance the consumer browsing experience and to support informed decision-maing. To assess progress, this report presents findings from a review of maretplace websites conducted between November 15th and December 23rd of 2014 by Manatt Health. To determine which aspects of maretplace websites are ey to supporting informed consumer decision-maing, reviewers interviewed academics, foundation staff, consumer advocates, and representatives of patient groups. From these interviews, four ey elements of website design were identified: (1) enhanced anonymous browsing; (2) direct access to ey plan features; (3) useful plan display and availability of consumer tools; and (4) easy website navigation and lins for assistance. Manatt Health then reviewed maretplace websites anonymous browsing features to evaluate their performance across these four dimensions. Manatt Health conducted two levels of review. To get an overall sense of the information and tools available to maretplace shoppers, Manatt first conducted a high-level review of all 15 maretplace websites: Healthcare.gov, which serves as the maretplace website for 37 states, 2 and the maretplace websites of 14 states. 3 Manatt then followed the high-level review with a more in-depth analysis of six select maretplace websites: Healthcare.gov and the maretplace websites of California, Colorado, Connecticut, New Yor and Washington state. In reviewing these six websites, Manatt too a detailed loo at the way they employ their anonymous browsing features to present information on plan choice and provide consumers with decision-maing support tools. NATIONAL PARTNERSHIP FOR WOMEN & FAMILIES REPORT SUPPORTING INFORMED DECISION-MAKING IN THE HEALTH INSURANCE MARKETPLACE 1

4 Key Findings For the 2015 open enrollment period, maretplace websites have adopted notable features that enhance transparency and support informed consumer decision-maing. At the same time, however, consumers still face a wide array of plan choices and it can be challenging to quicly and easily find the information needed to select a plan. As the maretplace continues to evolve, it will remain important to identify promising practices on which they can build. OPEN ENROLLMENT 2015 Nearly all maretplace websites now allow consumers to window-shop for plans. In the early days of the first open enrollment period, consumers were disappointed to find that they could not see their plan options unless they first established a maretplace account. Now, however, consumer ability to anonymously browse or window-shop prior to creating a maretplace account appears to be emerging as a standard practice across maretplace websites. As shown in Table 1, 13 out of 15 maretplace websites, including Healthcare.gov, now allow consumers to review plan options through an anonymous browsing function. 4 Some maretplace websites are creating new, easier ways for consumers to search for their providers and prescription drugs. Most consumers want health plans that include preferred providers in-networ and cover their prescription drugs. Four state-run maretplace websites 5 Colorado, Kentucy, Maryland and Washington offer consumers a tool to help mae it easier to find plans based on these preferences. These maretplace websites offer integrated provider directories as part of their anonymous browsing functions. These tools prompt the consumer to enter the name of a preferred provider and then generate a list of available plans that include that provider in their networs. Along with its integrated provider directory, the Colorado maretplace website also has established an integrated prescription drug directory that allows consumers to quicly and easily see which plans cover their medications. More maretplace websites are offering consumers smart tools and interactive features. As part of their anonymous browsing features, some maretplace websites are utilizing promising tools that are aimed at helping consumers quicly and easily personalize their plan selections. Washington s maretplace website has created a plan wizard that allows people to enter information about their plan preferences. The plan wizard then provides the consumer with customized plan options. Healthcare.gov now gives individuals the flexibility to decide how much personal information they want to enter when anonymously browsing for plans. Consumers can elect to provide personal information if they wish to view more accurate premium estimates that tae into account eligibility for financial assistance. Connecticut and Washington highlight Silver-level plan options for consumers who, when anonymously browsing for plans, appear eligible for cost-sharing reductions. These maretplace websites reorder displayed plan options to show Silver-level plans first an important feature since individuals who are eligible for cost-sharing reductions may only tae advantage of them if they enroll in a Silver-level plan. 6 2 NATIONAL PARTNERSHIP FOR WOMEN & FAMILIES REPORT SUPPORTING INFORMED DECISION-MAKING IN THE HEALTH INSURANCE MARKETPLACE

5 LOOKING AHEAD Across maretplace websites, there are strong features in place that support informed consumer decision-maing. However, maretplace administrators should continue to loo for ways to systematically review and improve how they help consumers analyze and select plans. Such efforts will help to ensure that the maretplace delivers on its intended purpose: helping consumers compare coverage options across standardized criteria and identify the plan that best meets their families health care needs and financial circumstances. There are a number of strategies that federal and state maretplace administrators should consider to improve consumers plan selection experience. For example, maretplace websites should enable enhanced anonymous browsing that provides consumers with the option of a customized browsing experience that reflects eligibility for financial assistance. Browsing features should facilitate, through tools such as integrated directories, ready access to information on ey plan features, including provider and facility networs and prescription drug formularies. Consumers should have direct access to comprehensive information on the total cost of plans: Information about deductibles, for instance, must be clear so that consumers understand their potential out-of-pocet costs. Finally, maretplace websites should display comprehensive information on quality ratings and enrollee satisfaction scores for each plan. To help consumers navigate their plan options, maretplace websites should utilize multiple strategies and tools to facilitate informed consumer decision-maing. Plans should be displayed in a priority order that taes into account multiple factors, including eligibility for financial assistance, total out-of-pocet costs, and consumer preferences with respect to in-networ providers and covered benefits and prescription medications. Additionally, maretplace administrators should explore the use of smart tools that wal consumers through the steps involved with selecting a plan by soliciting ey preferences and then displaying plan options that meet those preferences. Taing such steps will help to ensure that maretplace websites are facilitating transparency of information and supporting consumer decision-maing. A comprehensive list of recommendations is included in the report that follows. NATIONAL PARTNERSHIP FOR WOMEN & FAMILIES REPORT SUPPORTING INFORMED DECISION-MAKING IN THE HEALTH INSURANCE MARKETPLACE 3

6 Introduction A ey goal of the Affordable Care Act (ACA) was to create an insurance maret in which consumers would have the ability to compare coverage options across standardized criteria and identify the plan that best meets their families health care needs. In October 2013, the new health insurance maretplace, composed of the Federally-facilitated maretplace (Healthcare.gov) and 14 state-run maretplaces, officially launched. 7 As the second annual open enrollment period nears its close, 9.5 million individuals have enrolled in plans through the maretplace and millions more are now covered by Medicaid. 8 Due in large part to the ACA, the uninsurance rate in the United States is at an historic low of 11.3 percent. 9 As implementation of the ACA moves forward and the maretplace continues to evolve, the focus on consumer behavior and decision-maing is growing. A ey question for both advocates and policymaers is whether consumers have the tools required to support informed choice with regard to health plan selection in the maretplace. Recognizing that selection of the right plan one that meets a family s health care needs and preferences and aligns with its financial reality is ey to consumer satisfaction, there is increased interest in ensuring that consumers have easy access to reliable information about plan options and the tools that support informed decision-maing. This report loos at how well the maretplace is providing consumers with ey information about available health plans. It also assesses new tools and promising practices that maretplace websites are employing to enhance the consumer browsing experience and to support informed decision-maing. Drawing on current literature, expert interviews, and primary research conducted in November and December of 2014 by Manatt Health, this report identifies ey aspects of maretplace websites that support informed consumer decision-maing with respect to selecting a plan: (1) enhanced anonymous browsing; (2) direct access to ey plan features; (3) useful plan display and availability of consumer tools; and (4) easy website navigation and lins for assistance. (See Figure 1.) Using these factors, 4 NATIONAL PARTNERSHIP FOR WOMEN & FAMILIES REPORT SUPPORTING INFORMED DECISION-MAKING IN THE HEALTH INSURANCE MARKETPLACE

7 Manatt Health evaluated maretplace websites to see how they are using their anonymous browsing features to guide consumers to the best plans for themselves and their families, to identify promising practices currently being implemented on maretplace websites, and to offer recommendations for how the maretplace can continue to improve the consumer experience. As this report details, both Healthcare.gov, the website for the Federally-facilitated maretplace, and websites for state-run maretplaces are doing many things well with respect to helping support informed consumer decision-maing. Nearly all maretplace websites allow for anonymous browsing and several sites anonymous browsing features provide consumers with enhanced tools for identifying and comparing plans that fit their health care needs and financial circumstances. At the same time, however, there remains room for improvement: Consumers face a wide array of plan choices and several maretplace websites provide access only to limited information and offer few decision-maing tools to help consumers mae sense of their options as part of their anonymous browsing features. NATIONAL PARTNERSHIP FOR WOMEN & FAMILIES REPORT SUPPORTING INFORMED DECISION-MAKING IN THE HEALTH INSURANCE MARKETPLACE 5

8 Methodology-In-Brief To identify ey aspects of maretplace websites that support informed consumer decisionmaing, Manatt Health conducted expert interviews with academics, foundation staff, consumer advocates, and representatives of patient groups during the fall of Experts were ased to provide insight into the type of information that is most useful to consumers who are analyzing and comparing health plans, strategies for presenting that information effectively, and promising maretplace practices for promoting transparency and providing consumers with plan-selection tools. (See Appendix A for additional information.) Interviewee input was then used to identify ey dimensions of plan browsing that best support informed consumer decision-maing: (1) enhanced anonymous browsing; (2) direct access to ey plan features; (3) useful plan display and availability of consumer tools; and (4) easy website navigation and lins for assistance. To evaluate how maretplace websites are performing across these four dimensions, Manatt Health conducted two levels of review using maretplace websites anonymous browsing features between November 15th and December 23rd of To get an overall sense of the information and tools available to maretplace shoppers, Manatt first conducted a high-level review of all 15 maretplace websites: Healthcare.gov, which serves as the maretplace website for 37 states, 10 and the 14 maretplace websites run by states. 11 Manatt followed the high-level review with an in-depth analysis of six select maretplace websites: Healthcare.gov and the maretplace websites of California, Colorado, Connecticut, New Yor and Washington state. In reviewing these six websites, Manatt too a detailed loo at the way they employ their anonymous browsing features to present information on plan choice and provide consumers with decision-maing support tools. Both reviews only looed at plan data and plan choice tools available to the general public as part of a website s anonymous browsing feature. As a result, this study does not assess the shopping experience of consumers after they create maretplace accounts. In some instances, consumers who create accounts then have access to additional tools and information that simplify their plan shopping experiences. For example, New Yor s maretplace website gives individuals who create accounts access to an integrated provider directory and highlights Silver-level plans for those who are eligible for cost-sharing reductions (CSRs). 12 Finally, it is important to note that this study did not verify the validity of the data displayed by maretplace websites, such as the accuracy of plans provider directories. For more detailed information on the methodology used in this study, please see Appendix A. 6 NATIONAL PARTNERSHIP FOR WOMEN & FAMILIES REPORT SUPPORTING INFORMED DECISION-MAKING IN THE HEALTH INSURANCE MARKETPLACE

9 Open Enrollment 2015: Consumer Access to Health Plan Information and Decision-Maing Tools Based on interviews with experts, researchers identified the following dimensions as ey to informed consumer decision-maing: (1) enhanced anonymous browsing; (2) direct access to ey plan features; (3) useful plan display and availability of consumer tools; and (4) easy website navigation and lins for assistance. The following section provides a progress report on how Healthcare.gov and state-run maretplace websites are delivering on these elements. In addition to highlighting recent innovations, the report identifies promising practices that should be considered by all maretplace websites. Enhanced Anonymous Browsing In the early days of the first open enrollment period, consumers faced difficulty previewing plan options and prices before they created maretplace accounts. Many consumers expressed a strong preference for being able to browse maretplace plan options anonymously, before they were required to create accounts that required disclosure of personal information. Allowing consumers to anonymously browse or window-shop prior to creating maretplace accounts now appears to be emerging as a standard practice across maretplace websites. Based on the review conducted in November and December of 2014, the majority of maretplace websites allow consumers to review plan options through an anonymous browsing function without first requiring the creation of a personal account. Healthcare.gov maintains an anonymous browsing feature, as do 12 of the 14 state-run maretplace websites. Vermont and the District of Columbia are the only two state-run maretplace websites that do not fully allow for anonymous browsing of 2015 plans. (See Table 1.) At one point, the Vermont maretplace website did offer an anonymous browsing feature but the state decided to remove this feature upon deciding that the tool was unnecessary given that only two issuers offered plans in its maretplace. Vermont administrators concluded that there were better ways to present consumers with their options. While the District of Columbia s maretplace website does not offer comprehensive anonymous browsing, it does have a tool that allows consumers to compare plans across ey dimensions. This tool stops short of displaying premium data. 13 While most maretplace websites offer an anonymous browsing experience, there is wide variation in how maretplace sites balance providing an accurate portrait of consumers plan options (e.g., presenting premium or cost-sharing levels that tae into account a consumer s financial circumstances) with allowing consumers to shop completely anonymously. For many maretplace websites, complete anonymity while window-shopping comes at the cost of customization. For example, the maretplace websites run by Colorado, Minnesota and Massachusetts do not as consumers to input any financial information as part of their anonymous browsing features. As a result, consumers are only able to preview the full cost of plans; displayed plans are not adjusted to reflect the consumer s eligibility for premium tax credits or cost-sharing reductions (CSRs). Conversely, Healthcare.gov and nine state-run maretplace websites do solicit voluntary information on individuals circumstances as part of their anonymous browsing features and subsequently factor NATIONAL PARTNERSHIP FOR WOMEN & FAMILIES REPORT SUPPORTING INFORMED DECISION-MAKING IN THE HEALTH INSURANCE MARKETPLACE 7

10 that information in when presenting plan options. 14 Healthcare.gov, for example, allows consumers utilizing its window-shopping tool to decide how much personal information they want to enter. It notifies consumers that they have the option of entering more detailed information at any point in the browsing experience and that doing so will generate a more personalized array of plan choices. RECOMMENDATIONS: Enable enhanced anonymous browsing. All maretplace websites should offer an anonymous browsing feature that is as comprehensive as possible. The ability to browse plan options prior to creating a maretplace account is now a standard practice across nearly all maretplace websites. Provide consumers with the option of a customized anonymous browsing experience. Similar to what is available through Healthcare.gov, maretplace websites should provide consumers with the option to input personal information, such as household size and income, while windowshopping. Consumers should be informed that entering varying levels of personal information will enable the anonymous browsing tool to customize plan options to reflect the individual s eligibility for financial assistance. Direct Access to Key Plan Features During the first open enrollment period, many consumers found it difficult to access accurate information about maretplace plans provider networs, prescription drug formularies, and costsharing structures. Absent ready access to information on ey plan design features, consumers experienced barriers to comparing plans across multiple dimensions and maing well-informed decisions about their health insurance. The Centers for Medicare and Medicaid Services (CMS) has sought to improve consumer access to information on plan features, including provider directories and prescription drug formularies, through federal regulation and guidance. 15 In turn, maretplace websites have responded to changes in policy and consumer feedbac in a number of ways for the 2015 open enrollment period. While consumer access to information on ey plan features prior to creating a maretplace account has progressed, there remains room for improvement. 8 NATIONAL PARTNERSHIP FOR WOMEN & FAMILIES REPORT SUPPORTING INFORMED DECISION-MAKING IN THE HEALTH INSURANCE MARKETPLACE

11 To evaluate transparency in the maretplace for the 2015 open enrollment period, this study first sought to identify the plan features that are most valuable to consumers when browsing and comparing plan options. Interviews with experts highlighted the following elements: (1) ability to identify whether preferred providers and health care facilities are in a plan s networ; (2) ability to determine if a plan covers their prescription drugs; (3) ability to assess the total cost of a plan, including cost-sharing for covered services; and (4) ability to view and comprehend a plan s quality rating. This sub-section details how maretplace websites are performing with respect to these four elements. ACCESSIBILITY OF INFORMATION ON PROVIDER AND FACILITY NETWORKS As of December 2014, four state-run maretplace websites 16 Colorado, Kentucy, Maryland and Washington offer consumers integrated provider directories as part of their anonymous browsing functions. (New Yor s maretplace website does mae an integrated provider directory available to consumers who create maretplace accounts, but this tool is not available as part of the website s anonymous browsing feature.) Integrated directories allow consumers to enter the names of their health care providers and facilities into a search tool. The tool then generates and displays available maretplace plans that include those providers and/or facilities in their networs. Such tools, which give consumers ready access to information on provider networs, stand out as a promising practice that should be utilized across all maretplace websites. Currently, however, Healthcare.gov and most state-run websites require consumers who are anonymously browsing to visit the online provider directory of each separate plan they are considering to determine if the plan includes their preferred providers. These window shoppers are not consistently provided with a direct lin to each plan s provider directory. 17 ACCESSIBILITY OF INFORMATION ON PRESCRIPTION DRUG COVERAGE In addition to being able to identify which plans include preferred providers in-networ, consumers highly value being able to access information on whether a plan covers their medications. In the first open enrollment period, consumers found it difficult to determine what drugs were included in plans drug formularies and to understand cost-sharing responsibilities for covered prescriptions. Consumer advocacy groups and patient organizations have been vocal about the need to ensure that maretplace plans provide direct lins to their drug formularies. NATIONAL PARTNERSHIP FOR WOMEN & FAMILIES REPORT SUPPORTING INFORMED DECISION-MAKING IN THE HEALTH INSURANCE MARKETPLACE 9

12 In evaluating how select maretplace websites have responded to consumer concerns and regulatory direction 18 about access to prescription drug coverage, this study found that consumers are not consistently provided with direct lins to drug formularies when window-shopping for plans. As with provider directories, consumers are sometimes able to lin directly to a drug formulary when browsing a plan; in many cases, however, plan lins direct window shoppers to a general website or instruct them to enter plan details in order to access formulary information. Inconsistent access to direct formulary lins was observed across Healthcare.gov and four of the five state-run maretplace websites reviewed in-depth as part of this study. 19 Colorado, however, has found a promising way to improve transparency of prescription drug coverage for consumers anonymously browsing plans on its state-run website. The Colorado maretplace website features an integrated prescription drug directory that allows consumers to enter the names of their medications into a search tool. The search tool then displays available plans that cover those specified medications. ACCESSIBILITY OF INFORMATION ON COST-SHARING To ensure selection of a plan that not only meets their health care needs but also aligns with their financial circumstances, consumers must be able to access and assess information on the total cost of a health plan, inclusive of both premium and cost-sharing responsibilities. Supporting consumer access to and comprehension of plan cost-sharing structures, such as copays, coinsurance and deductibles, is ey to facilitating informed consumer decision-maing in the maretplace. Indeed, maretplace websites are required to provide consumers with basic information about the cost-sharing structure of plans. While maretplace websites generally are displaying cost-sharing information as part of their anonymous browsing features, questions remain as to how well consumers are able to use this information without significant assistance. As of December 2014, maretplace websites varied with regard to the level of detail they provided window shoppers. This study identified considerable variance with respect to available information on cost-sharing by service. For example, while Washington s and Colorado s maretplace websites highlight that preventive services are not subject to a plan s deductible, many other maretplace websites do not emphasize this important information. In addition, maretplace websites do not consistently clarify 10 NATIONAL PARTNERSHIP FOR WOMEN & FAMILIES REPORT SUPPORTING INFORMED DECISION-MAKING IN THE HEALTH INSURANCE MARKETPLACE

13 whether a plan s deductible applies to other specific types of care, such as prescription medicines or provider office visits. In some cases, the information on deductibles displayed on the maretplace website was not consistent with the plan s Summary of Benefits and Coverage document. ACCESSIBILITY OF INFORMATION ON PLAN QUALITY RATINGS AND OTHER PERFORMANCE METRICS Finally, in addition to ready access to information on a plan s benefit and cost-sharing design, provider directory, and prescription drug coverage, the ability to assess how a plan performs on quality metrics also supports informed consumer decision-maing. As consumers are confronted with plans offering narrower provider networs, being able to determine how a plan performs with respect to quality and consumer satisfaction is increasingly important. For plan year 2017, maretplace websites will be required to provide consumers with comprehensive information about the quality of the health plans they offer by displaying both quality ratings and the results of enrollee satisfaction surveys. Some maretplace websites are already displaying alternative quality data. Of the maretplace websites reviewed in-detail in this study, only one California s consistently provides information on plans quality ratings. Connecticut s and Washington s maretplace websites offer limited information on plan quality, but do not display actual quality ratings or information on enrollee satisfaction. For example, the Connecticut maretplace website indicates whether plans are accredited by the National Committee for Quality Assurance (NCQA). The Washington maretplace website includes a description of each plan s quality improvement strategy. As the maretplace continues to evolve, consumer access to quality ratings and enrollee satisfaction survey results will play a greater role in supporting informed consumer decision-maing. RECOMMENDATIONS: Facilitate consistent and direct consumer access to information on ey plan features, including provider directories, prescription drug formularies, and deductibles as well as other costsharing information. While promising practices are evident, consumers still face barriers to easily accessing plans provider directories and drug formularies. Consumers must be easily able NATIONAL PARTNERSHIP FOR WOMEN & FAMILIES REPORT SUPPORTING INFORMED DECISION-MAKING IN THE HEALTH INSURANCE MARKETPLACE 11

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