FRAMEWORK FOR MONITORING

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1 FRAMEWORK FOR MONITORING THE MARYLAND HEALTH CONNECTION DRAFT - Proposed Measures December, 2012 Prepared for The Maryland Health Connection Funded by Submitted by Elizabeth Lukanen, MPH Kelli Johnson, MBA

2 Introduction The federal Patient Protection and Affordable Care Act (the ACA), enacted in March 2010, will have far-reaching impacts on health insurance coverage, health care financing, and health care delivery in the United States. Understanding the state-level impacts of the ACA will be a top priority for state policymakers and will guide ongoing state implementation activities. The purpose of this report is to present a set of measures that the Maryland Health Connection (also referred to as the exchange ) can use to monitor the impact of the exchange. The measures are organized into five core measurement categories developed by Maryland Health Connection staff: Access, Affordability, Consumer Satisfaction, Stability and Health Equity. This report identifies unique measures for the first four categories. The fifth category, Health Equity, is addressed using key measures from other categories with proposed additional tracking by race, income, geography and age. Figure 1 is a high level summary of the proposed measures by category. The five core measurement categories are broad, and there are numerous measures that could be used to track trends in each area. A key goal of this report is to propose a limited number of high-priority measures focused on the activities of the exchange and on the populations served by the exchange. In addition, the proposed measures are limited to data that could be generated through the operation of the exchange, measures currently produced by other state agencies or measures that draw on data currently collected or analyzed by the state. Given Maryland s vast data resources and broad technical expertise there were a variety of measures and data to choose from. The majority of measures and underlying data come from four key agencies: The Maryland Department of Planning, the Health Services Cost Review Commission (HSCRC), the Maryland Health Care Commission (MHCC), Department of Health and Mental Hygiene (DHMH). It is important to note, that the agencies listed as possible data resources have not formally committed to producing new analyses. The approach to measure selection was to get a broad view of the data resources in the state, assess these data against the goals of the exchange and to identify gaps. SHADAC first conducted a scan to identify measures and data currently being produced or collected by the state. This included a review of public documentation and interviews with agency staff familiar with key data sources. Next, SHADAC assessed the data using a set of defined criteria (e.g. timeliness, completeness, ability to measure subpopulations of interest, etc.). Finally, SHADAC conducted a gap identifying key pieces of information that will benefit the effort and that can likely be generated by the exchange or through minimal effort by other agencies. The narrative of this report contains a definition for each of the proposed measures, a recommended data source, a source for and a section describing the measure s value to a monitoring effort. For most of the measures, it will also be desirable to monitor trends at a level more detailed than that provided by statewide totals. While not all of these data support subpopulation, some do and recommendations have been made on the various subgroups that should be tracked. Figure 2 provides the information outlined above in a more summary format and also includes information on the timing of the data collection and any significant data lags. As noted, many of the proposed measures will rely on data related to or collected by the exchange. However, as the exchange is still being developed, what can be collected and reported remains somewhat uncertain. For example, it is unclear whether insurance market data collection will change in 2014 to distinguish coverage that was purchased through the exchange, which has implications for the development of the enrollee satisfaction survey tool referenced in this report. In these instances we have kept the recommendations broad and/or suggested ideal approaches. 2

3 Figure 1: Summary of Recommended Measure for Monitoring the Maryland Health Connection Access 1. Number of individuals that attempt to obtain coverage through exchange 2. Number of employers that attempt to obtain coverage through exchange 3. Number of individuals who enroll in coverage through the exchange 4. Number of employers that facilitate coverage through the exchange 5. Distribution of insurance status 6. Number of ambulatory care sensitive condition hospital admissions per 100,000 Affordability 1. Number of individuals receiving premium subsidies 2. Number of individuals receiving cost sharing subsidies 3. Premium cost 4. Employee contribution to premium 5. Percentage of adults who cannot afford a doctor visit 6. Percent of families with high cost burden 7. Affordability Index Consumer Satisfaction 1. Application processing time 2. Number of grievances 3. Composite measure of satisfaction Stability 1. Number of individuals exempt from the mandate 2. Number of insurance companies in the state 3. Number of covered lives 4. Number of employers offering coverage 5. Percent of employees in firms that offer coverage 6. Percent of employees that are enrolled in ESI 7. Uncompensated hospital care costs 8. Number of seamless coverage transitions 9. Number of nonseamless coverage transitions Health Equity 1. Number of individuals that attempt to obtain coverage through exchange (Access) 2. Distribution of insurance status (Access) 3. Number of individuals receiving premium subsidies (Affordability) 4. Number of individuals receiving cost sharing subsidies (Affordability) 5. Percentage of adults who cannot afford a doctor visit (Affordability) 6. Percent of families with high cost burden (Affordability) 7. Composite measure of satisfaction (Consumer Satisfaction) 3

4 Access While expanded insurance coverage is a crucial step toward the ACA s ultimate goal of better access to needed health care services, insurance coverage by itself does not ensure access to services. For this reason, a primary goal of the Maryland Health Connection is to both reduce the number of Marylanders without health insurance and improve access to health care services for all Marylanders. To monitor the success of the exchange in this area we propose the following measures. 1. Number of individuals that attempt to obtain coverage through exchange. The total number of unique person-level IDs that are generated when an individual creates an account with the exchange. 2. Number of employers that attempt to obtain coverage through exchange. The total number of unique employer IDs that are generated when a business creates an account with the exchange. To the extent that individuals and employers have multiple avenues for accessing the exchange, these various entry points should be tracked separately. This measure will require new data collection and best generated by the exchange. Both of these measures will be useful in tracking the overall traffic into the exchange and changes in demand over time. They can be used in combination with the number of individuals that actually obtain coverage to calculate application success rates, which can highlight the exchange s ability to facilitate enrollment or signal potential problems with the enrollment process. 3. Number of individuals who enroll in coverage through the exchange. Number of individuals who enroll in a public program or qualified health plan (QHP) via the exchange. This measure should be tracked by the following: Previous source of coverage, coverage type (non-group, group, Medicaid) and precious metal tier choice. Data for this measure will need to be newly generated by the exchange. This measure can be used to highlight early successes as individuals obtain coverage through the exchange. Measuring this by previous source of coverage can highlight coverage gains among the previously uninsured, but also provide an early warning sign of employers possibly dropping coverage. Tracking enrollment by coverage type will help illustrate whether the exchange is being used and is making it easier for individuals to gain coverage regardless of whether they are eligible for financial assistance (Medicaid or subsidies). 4. Number of employers that facilitate coverage through the exchange. Number of employers who facilitate insurance enrollment through the exchange. This measure should be tracked by: Receipt of tax credit, firm size, industry and previous offer of coverage. The data to support this measure will need to be produced by the exchange. It is important to measure the impact of the exchange on employers and on their workers. Measuring this by different subgroups can indicate whether the exchange is reaching firms of various sizes (e.g., very small firms) and industries, as well as attracting firms eligible for the tax credit or not. In addition, measuring this by previous source of coverage can highlight success in facilitating new offers of coverage by employers that didn t previously offer it and success in capturing participation among by employers that currently do offer coverage. 4

5 5. Distribution of insurance status. Statewide population count of insurance coverage. This should also be analyzed by an individual s primary source of coverage. i Data for this measure can come from the American Community Survey (ACS), a state representative federal survey. ii The Maryland Department of Planning does extensive using the ACS and should be considered a potential source for this new. In addition to monitoring coverage changes in the exchange, it is important to track the overall coverage dynamics of the state. Most importantly, this statewide measure can be used to monitor changes in the number of uninsured Marylanders and broad shifts in population coverage types. 6. Number of ambulatory care sensitive condition hospital admissions per 100,000. Statewide, agestandardized acute care hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission to the hospital, per 100,000 population under age 75 years. iii This measure should be tracked separately for children and adults. Data for this measure are collected by the Health Services Cost Review Commission (HSCRC) and the rate is calculated by the Maryland Health Care Commission (MHCC). This measure can be used to indicate access to appropriate primary health care. It can be tracked over time to indicate reduced barriers to access related to coverage gains. This measure On the other hand, it could also signal provider capacity issues resulting from an increase in insured individuals seeking primary care services. 7. Uncompensated hospital care costs. Percentage difference between billings at established rates and the amount collected from charity patients and patients who pay nothing or less than their total bill (composed of charity care and bad debt). Data for this measure are collected and reported by the HSCRC. This aggregate measure of bad debt and charity care can be used to measure the size of demand for safety net services. While initial trends in charity care will go down with coverage gains, long term monitoring of charity care can confirm continued coverage levels or signal coverage losses or possible issues with affordability of cost sharing. 8. Number of seamless coverage transitions. The number of individuals who transfer from one type of coverage obtained through the exchange (e.g., QHP or Medicaid) to another type of coverage obtained through the exchange by the following month. iv 9. Number of non-seamless coverage transitions. The number of individuals who transfer from one type of coverage obtained through the exchange (e.g., QHP or Medicaid) to another type of coverage obtained through the exchange following a gap in coverage of one to six months. v These measures should be tracked in two ways: by previous coverage status/ type (non-group, group, Medicaid) and by enrollee income. Data for these measures will need to be collected by the exchange. Coverage gaps can be defined as a lack of coverage obtained through the exchange for one to six months or based on an enrollee report of a coverage gap. These measures can be used to monitor how well the exchange does in assisting individuals transitioning between coverage types as their eligibility changes. This can be used to inform investments for navigators, in-person assisters, and web tools. Monitoring this by coverage status and income can highlight specific areas of success and weakness (e.g., the exchange may do well assisting people as they transition from Medicaid and subsidized OHPs, but poorly assisting people as they move from unsubsidized coverage into a subsidized plan). 5

6 Affordability Many of the key aims of the exchange are aimed at increasing the affordability of health insurance premiums while simultaneously ensuring a minimum level of covered benefits and financial protection. The exchange will facilitate subsidies for individuals and employers, ensure a minimum level of covered benefits and financial protection, and streamline enrollment processes to ease administrative costs. A guiding principle of the Maryland Health Connection is that affordability of coverage within the exchange and in the state as a whole is essential to improving Maryland s health care system and economy. To monitor the success of the exchange in this area we propose the following measures. 1. Number of individuals receiving premium subsidies. The number of individuals receiving some level of premium subsidy. 2. Number of individuals receiving cost sharing subsidies. The number of individuals receiving cost sharing subsidies. This measure should be tracked by income (using the range specified in law to calculate the subsidy level) and precious metal tier choice (for those getting premium subsidies). An additional calculation of average value of premium and cost sharing subsidies should also be produced. Though the federal government will have these data, it is unclear whether they will release the information, and, if so whether the format or timeframe will be appropriate for state exchange monitoring. For this reason, this measure should be filled using new data generated by the exchange. A primary function of the exchange is to facilitate the transfer of premium and cost sharing subsidies to individuals. Monitoring the number of people receiving a subsidy, as well as the value of the subsidy, will both highlight the successful functioning of the exchange and help track the federal resource allocation to this provision of the ACA. Tracking this by income can help the exchange monitor whether it is successfully reaching eligible individuals of all incomes (particularly important for those at the high end of the range). 3. Premium cost. Average annual premium cost. Ideally, premium costs could be monitored for the entire health insurance market and tracked for the small-group and non-group markets, both in and out of the exchange. Currently, no single data source contains information for all markets and subgroups of interest. The approach outlined below relies on currently available data and can be updated if a more comprehensive data source becomes available. New data collection would need to be done by the exchange to monitor premium trends in their market. This should be tracked for both single and family plans and for the small-group and non-group market. To monitor trends in the market as a whole, data from the federal Medical Expenditure Panel Survey - Insurance Component (MEPS-IC) can be used to track premiums in the employer-sponsored insurance (ESI) market. This should be tracked for both single and family plans and in and outside the exchange (not currently possible). vi Health insurance premiums are a key component of individual-level affordability and commonly used monitor affordability more generally. Given the regulatory and coverage changes associated with the ACA, this is a crucial measure of interest. In the short term, rate fluctuations may make this measure difficult to analyze, but long term monitoring of this measure will provide important indications of coverage affordability. Tracking these measures separately in the group and non-group markets can help the exchange monitor the impacts of various state and federal policy actions. By taking a market wide approach, the exchange can monitor variations in premium trends in and outside the exchange. 6

7 4. Employee contribution to premium. Average employee contribution to an annual premium. Ideally, this measure should be reported for single and family coverage as well as in and outside the exchange (not currently possible). vii Data to fulfill this measure are collected through the MEPS-IC and are analyzed by the MHCC. Monitoring employee contribution to premium is important because employees often make coverage decisions based on their share of the premium (as opposed to the premium as a whole). Tracking this measure over time also provides some insight into employer attitudes about contributing to insurance coverage. 5. Percentage of adults who cannot afford a doctor visit. Number of adults who could not see a doctor due to cost. Data for this measure are collected and analyzed by Maryland Department of Health and Mental Hygiene (DHMH) using the Maryland Behavioral Risk Factor Surveillance System (BRFSS), a state-level survey conducted in partnership between the federal government and states. viii This statewide measure is useful for tracking overall trends in affordability. In addition, by focusing on this specific aspect of the concept, the exchange can use the measure to tell the affordability story from a very personal point of view. 6. Percent of families with high cost health care burden. The percent of families that spends more than 10% of their income on premiums and out-of-pocket spending statewide. While a standard measure for affordability does not exist, 10% of family income is a very commonly used measure. Data for this measure is available from the Current Population Survey (CPS), a federal survey capable of producing state-level estimates. ix The Maryland Department of Planning does extensive using the CPS and should be considered a potential source for this new. By highlighting total spending, both premiums and out-of-pocket spending, this statewide measure provides a comprehensive view of affordability. Because this measure is at the family level, it is easy for individuals to relate to and therefore useful for illustrating affordability gains to the public. 7. Affordability Index In addition to the measure above, exchange staff would like to include a measure based on an affordability index. Details on this measure are forthcoming. Consumer Satisfaction The Maryland Health Connection will serve as the primary face for health reform in the state. It will act as a hub for individuals and small employers seeking insurance coverage. By 2020, the exchange is expected to serve almost 300,000. x It will play many consumer-facing roles related to enrollment such as determining whether employers and individuals qualify for federal tax credits and subsidies and whether individuals are eligible for Medicaid. For all of these reasons, consumer satisfaction is a key goal of the exchange. To monitor the success of the exchange in achieving and monitoring high levels of consumer satisfaction, we propose the following measures. 1. Application processing time. Time lag between first point of contact with the exchange to coverage eligibility determination. This measure should be tracked for individuals and employers. The measure is made up of two data points, both of which need to be newly generated by the exchange. The initial data point for this measure can be defined in various 7

8 ways depending on how the exchange enrollment process is set up. For instance, it can be the point at which an individual or employer ID is generated or the point at which 100% of the application data is submitted or verified. The second data component should be the point at which a determination of coverage eligibility is made (e.g., Medicaid eligible, eligible for a subsidy, etc.). DRAFT Although this does not measure consumer attitudes directly, it is an early driver of satisfaction and will be important to monitor along with direct measures of satisfaction. It can also provide useful context for other measures of satisfaction. 2. Number of grievances. Total number of grievances filed with the exchange. This measure should be tracked for individuals and employers. Ideally, this could also be tracked by grievance type as well. The data for this measure will be newly collected by the exchange. Though this measure is fairly blunt and high level, the data that support it are continually generated and can provide a close to real time view of consumer satisfaction with the exchange. To the extent that the grievance reporting is broad (subject to a variety of exchange activities such as the online application process, information verification, eligibility determination, billing, etc.) and the data collection is standardized, this tracking can indicate individual attitudes toward the exchange in various areas. If these more detailed breakdowns are available, it can signal areas of success and areas where improvement is needed. 3. Composite measure of satisfaction. A measure that combines multiple dimensions of individual consumer satisfaction. This measure should be tracked by coverage type (non-group, group, Medicaid), receipt of a subsidy and precious metal tier choice. These data will be newly generated by the exchange via an enrollee satisfaction survey. Appropriate survey measures will be rolled into one or more composite measures of satisfaction. Components of this measure might include satisfaction with exchange enrollment process, health plan options or tools offered to make coverage decision, etc. A satisfaction survey is the most direct and reliable way to gauge individual perceptions of the exchange and of health insurance coverage more specifically. By creating a composite measure, many aspects of consumer satisfaction can be reflected in a single measure that is easy to display and monitor over time. When this measure is produced, it can reference more detailed survey measures to explain trends and highlight specific areas of note. Stability The creation of the Maryland Health Connection is accompanied by a great number of ACA provisions that will impact the market. In addition to increases in health insurance coverage there will be coverage shifts, premium impacts and changes to market risk pools. Mindful of this dynamic situation, a guiding principle of the exchange is to respect existing strength of the state s health care system and promote stability within the exchange. To monitor the success of the exchange in this area, we propose the following measures. 1. Number of individuals exempt from the mandate. Number of individuals exempt from the insurance coverage mandate for any reason. This measure should be tracked by the reasons for the exemption and will be generated by the exchange. The stability of the exchange relies in part on strong and stable participation. By tracking this measure the exchange has another measure for monitoring the overall strength of the exchange. This measure can also inform stability by 8

9 providing a gauge of affordability, particularly over time. Specifically, if subsidies are not sufficient to offset costs or premiums increase faster than wage growth, individuals will find coverage through the exchange unaffordable and will increasingly seek exemptions. 2. Number of insurance companies in the state. Number of companies with covered lives in the state. 3. Number of covered lives. Number covered lives in the state. DRAFT This measure should be tracked for the non-group, small group market and large group markets. In addition, should be produced to track the market share of the top three companies in each market. Ideally, covered lives would also be tracked in and outside the exchange to accurately measure market penetration. xi Data to construct these measure are reported to the National Association of Insurance Commissioners (NAIC ) as part of Medical Loss Ratio financial reporting. The data can be requested directly from the NAIC or the Maryland Insurance Administration (MIA), but will require some new compilation and. These measures can be used to track the overall stability of Maryland s insurance markets. Tracking the flow of companies entering or leaving certain market can indicate the changing cost of entering the markets and can be related to issues of access continuity at the enrollee level. Tracking covered lives both provides an idea for the size and stability of each of the markets, which can inform issues of overall stability and affordability. 4. Number of employers offering coverage. Number of private-sector employers that offer insurance, statewide. 5. Percent of employees in firms that offer coverage. Percent of private-sector employees in establishments that offer insurance. 6. Percent of employees that are enrolled in ESI. Percent of private-sector employees who are eligible for and enroll in coverage. It is useful to track these measures by firm size and industry if sample size allows. Data to fulfill these measures are collected through the MEPS-IC and are analyzed by the MHCC (slight modifications might need to be made to meet the exact specification indicated above). When thinking about insurance market stability, it is crucial to understand the changing dynamics of the market s foundation ESI. These measures have key implications for the sustainability of the exchange. Specifically, if ESI offer and coverage rates decline, an increasing number of people will be eligible for public coverage or subsidies thus raising the cost to the state and federal government. From an employer perspective, this measure provides insights into employers decisions about whether to offer or drop coverage. Since the majority of employers are small, but the majority of employees work in large firms that tend to have higher offer rates, it is useful track this by number of employees as well. Tracking the number of eligible workers that take up coverage is also useful, particular to monitor the impact of the coverage mandate. Health Equity The launch of the Maryland Health Connection and associated provisions of the ACA will undoubtedly lead to gains in coverage. The measures laid out above seek to monitor this increased access, assess affordability, and gauge the level of consumer satisfaction with the exchange. Though the measures provide an adequate overall view, the exchange places a high value on health equity and seeks to address disparities in health access and outcomes in the state. To do this, we recommend future subgroup of some of the measures presented in the sections addressing access, affordability and consumer satisfaction. 9

10 Wherever possible, the following measures should be tracked by race, income, geography, and age. Recognizing data limitations, the following additional subgroup tracking is recommended: 1. Number of individuals that attempt to obtain coverage through exchange (Access): by race, income geography and age. 2. Distribution of insurance status (Access): by race, income, geography and age. 3. Number of individuals receiving premium subsidies (Affordability): by race, geography and age. 4. Number of individuals receiving cost sharing subsidies (Affordability): by race, geography and age. 5. Percentage of adults who cannot afford a doctor visit (Affordability): by race 6. Percent of families with high cost burden (Affordability): by race 7. Composite measure of satisfaction (Consumer Satisfaction): by race, geography, income and age. Conclusion This report outlines a set of measures that the Maryland Health Connection can use in establishing its plans for monitoring the impact of the exchange across the five core measurement categories identified by Maryland Health Connection staff: Access, Affordability, Consumer Satisfaction, Stability and Health Equity. These categories are broad and there are numerous measures that could be used to track trends in each area. This report has proposed a limited number of high-priority measures focused on the activities of the exchange and on the populations served by the exchange. As noted, some of the data needed for these measures will need to be collected by the exchange itself, while others can be accessed from other state or federal sources as described in the report. 10

11 Figure 2. Recommended Measures for Monitoring the Maryland Health Connection ACCESS Measure Subgroup Options Data Source Availability Timing Number of individuals that attempt to obtain coverage through exchange Number of employers that attempt to obtain coverage through exchange Entry point (if different entry points exist) Method /Portal of entry Number of individuals who enroll in coverage through the exchange Previous source of coverage Non-group Group Medicaid Precious metal tier choice Number of employers that facilitate coverage through the exchange Receipt of tax credit Firm size Industry Previous offer of coverage Distribution of insurance status Calculation of interest: Primary source of coverage Federal survey data American Community Survey Maryland Department of Planning Collected Annually 8-10 month lag New Analysis Number of ambulatory care sensitive condition hospital admissions per 100,000 Age (adults versus children) Health Services Cost Review Commission (HSCRC) Inpatient Discharge Data Maryland Health Care Commission (MHCC) Collected quarterly Reported annually Uncompensated hospital care costs HSCRC Annual Cost Reports HSCRC Collected and reported annually 11 to 12 month lag Number of seamless coverage transitions Previous source of coverage Income 11

12 Number of non-seamless coverage transitions Previous source of coverage Income AFFORDABILITY Measure Subgroup Options Data Source Availability Timing Number of individuals receiving premium subsidies income Precious metal tier choice Calculation of interest: Average value Number of individuals receiving cost sharing subsidies income Calculation of interest: Average value Premium cost Single vs. family In/outside the exchange Employer sponsored insurance (ESI) vs. non-group Employee contribution to premium Single vs. family In/outside the Exchange Exchange only: Exchange Health plan data ESI only: Medical Expenditure Panel Survey - Insurance Component (MEPS-IC) ESI only: MHCC Collect quarterly report Collected and reported annually 6-7 month lag MEPS-IC MHCC Collected and reported annually 6-7 month lag Percentage of adults who cannot afford a doctor visit Maryland Behavioral Risk Factor Surveillance Survey Department of Health and Mental Hygiene (DHMH) Collected annually 5-6 month lag Report annually Percent of families with high cost burden Federal survey data: Current Population Survey MHCC New Collected annually 9-10 month lag Report two year average annually 12

13 Affordability Index TBD TBD TBD TBD Measure Subgroup Options Data Source Availability Timing Application processing time Method by which individuals entered the exchange (web, navigator, other) Number of grievances Individual vs. SHOP In/outside exchange Collected quarterly Reported annually 9 month lag Composite measure of satisfaction Previous source of coverage Non-group Group Medicaid Precious metal tier choice Exchange Enrollee Satisfaction Survey Collect and report annually STABILITY Measure Subgroup Options Data Source Availability Timing Number of individuals exempt from the mandate Number of insurance companies in the state Number of covered lives Non-group vs. ESI Calculation of interest: market share of top three companies Number of employers offering coverage Reason Non-group vs. ESI National Association of Insurance Commissioners (NAIC) Medical Loss Ratio Financial Reporting Firm size Industry NAIC Medical Loss Ratio Financial Reporting NAIC or Maryland Insurance Administration (MIA) New compilation and required. NIAC or MIA New compilation and required. Collected annually Lag unknown Report annually Collected annually Lag unknown Report annually MEPS-IC MHCC Collected annually Two year average reported annually 6-7 month lag Percent of employees in firms that Firm size MEPS-IC MHCC Collected annually 13

14 offer coverage Industry Two year average reported annually 6-7 month lag Percent of employees that are enrolled in ESI Firm size Industry Measure Subgroup Options Data Source Availability Timing Number of individuals that attempt to obtain coverage through exchange (Access) Distribution of insurance status (Access) Number of individuals receiving premium subsidies (Affordability) Race Income Geography Age Race Income Geography Age Race Geography Age Federal survey data American Community Survey Maryland Department of Planning New Analysis Collected Annually 8-10 month lag Number of individuals receiving cost sharing subsidies (Affordability) Race Geography Age Percentage of adults who cannot afford a doctor visit (Affordability) Race Maryland Behavioral Risk Factor Surveillance Survey DHMH May require additional Collected annually 5-6 month lag Report annually Percent of families with high cost burden (Affordability) Race Federal survey data: Current population survey MHCC New Collected annually 9-10 month lag Report two year average annually Composite satisfaction measure (Consumer Satisfaction) Race Income Geography Age Exchange Enrollee Satisfaction Survey Collect and report annually 14

15 i Primary source of coverage is generated by assigning a primary source of coverage for individuals with multiple sources following a logical hierarchy such as 1) Medicare, 2) ESI, 3) Medicaid, 4) Individually purchased coverage. ii For more information on the American Community Survey (ACS) please visit the SHADAC ACS resource page: iii This is the standard definition generated by the Agency for Health Care Research and Quality (AHRQ). iv Adapted from work done by Chris Trenholm at Mathematical for the Maximizing Enrollment program: v Adapted from work done by Chris Trenholm at Mathematical for the Maximizing Enrollment program: vi The Medical Expenditure Panel Survey - Insurance Component doesn t currently track whether plans are purchased through an exchange. Efforts to make this distinction in the future are unclear. vii The Medical Expenditure Panel Survey - Insurance Component doesn t currently track whether plans are purchased through an exchange. Efforts to make this distinction in the future are unclear. viii For more information on the Maryland Behavioral Risk Factor Surveillance (BRFSS) visit the Maryland BRFSS website: ix For more information on the Current Population Survey (CPS) please visit the SHADAC CPS resource page: x Based on July, 2012 model estimates produced by the Hilltop Institute: xi Current NAIC reporting guidelines do not track whether coverage was purchased through the exchange. Efforts to make this distinction in the future are unclear. 15

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