Exchange directors, the Centers for Medicare and Medicaid Services, and insurers have an enormous opportunity to help consumers choose the plan that is right for them and make the enrollment process more efficient by improving the display of plan information on marketplace websites. State advocates and enrollment assisters can help by providing recommendations: In state-based marketplaces, they can share recommendations during exchange advisory committee or board meetings as well as through communications to their state exchange director; in the federal marketplace, they can communicate with regional or national CMS officials. A new survey of Enrollment Assisters by Families USA highlights areas in which consumers and assisters want more information:
- Services covered before the deductible is met
- Out-of-pocket costs for drugs
The survey also identified two search features introduced in some marketplace websites last year that could be helpful to consumers and assisters, but have not yet been widely used and could be improved:
- Medical management programs
- Estimate of family’s yearly costs, including premiums and costs for care
Lastly, in the survey, assisters note needs for more accurate information about:
- Plan provider networks
Almost all assisters use tools on marketplace websites that let them sort plans by metal level and by premium costs, and they find these sorts useful in assisting with plan selection. They noted the following areas where marketplace websites should provide more or better information.
- Pre-deductible coverage of services: All plans cover required preventive services without cost-sharing. But a number of plans cover services beyond those before the deductible needs to be met (pre-deductible). In Families USA’s survey, half of assisters (50 percent) are aware of marketplace plans in their areas that make some services available before the deductible is paid off. And when assisters are aware of plans offering pre-deductible coverage of services, 74 percent say that the availability of pre-deductible service is always or often important to consumers’ plan choices. But even these assisters often cannot tell which specific services are covered pre-deductible in all plans in their areas. Among the assisters who were aware of any plans in their area offering pre-deductible services, only 40 percent said they could determine all of the plans in their area that offered pre-deductible services in addition to preventive care. Improving the display of pre-deductible services could greatly enhance enrollment, addressing some consumer concerns about whether they will be able to afford certain needed services in their plans.
- Drug coverage: About three-quarters of assisters (76 percent) have searched for drug coverage information for a client or clients. Knowing whether a plan covers a prescribed drug, what copayments or coinsurance the consumer must pay for that drug, and what alternative drugs the plan covers, can make a difference as to whether a particular plan is the best choice for a consumer. So as of 2016, federal rules require insurance companies to provide a direct link to the formulary for each of their specific health plans, which lists the drugs that are covered. The formulary must also list the “tier” on which each drug is covered (for example, whether it is a generic, preferred brand name, other brand name, or specialty drug) – but the formulary is not required to explain what this means for a consumer. Some marketplace websites do provide a search tool to enable consumers to determine if plans covered their specific drugs and a majority (85 percent) of assisters found it useful when helping clients with plan selection. However, a number of assisters still note problems obtaining information about drug coverage. Among assisters who have helped clients search for drug coverage information, 26 percent said that when they searched for drug coverage information, they could seldom or never determine whether a prescription drug was covered by the plan. Moreover, 31 percent of those assisters said that when they searched, they could seldom or never determine what a consumer would pay in cost-sharing for a drug. Assisters and consumers would benefit from a more integrated drug search tool that allowed them to determine in one step not only the tier on which a drug is covered, but also how much that drug will cost the consumer in copayments or coinsurance.
- Medical management programs: The federal marketplace currently allows viewers to search for plans that have “medical management programs,” defined on healthcare.gov as “programs that work closely with you to manage certain medical conditions.” The listed medical management programs are for asthma, heart disease, depression, diabetes, high blood pressure and high cholesterol, low back pain, pain management, pregnancy, and weight loss. But finding any information about what a medical management program entails still requires digging through plan documents, which may be why over half of assisters (54%) with access to that tool did not find medical management information useful in the plan selection process. Further, there are no particular requirements that plans need to meet to claim that they have a medical management program, so the quality and scope of these programs may vary enormously. Plans should have to meet some requirements to claim that they have a medical management program, and consumers and assisters should have ready access to information about what each program entails.
- Estimate of family’s yearly cost: This year, the federal marketplace and some state marketplaces included an estimator of a person or family’s yearly costs in a plan, including premiums plus out-of-pocket costs for care, depending on their expected use of medical care. Some marketplaces asked people to rank their expected use as high, medium, or low, for example, and others asked about specific expected medical procedures. Fifty-eight (58) percent of assisters in marketplaces that included a yearly cost estimator found the estimator to be useful. Assisters want to be able to understand the total costs consumers will face in a plan, and they will be better able to evaluate the usefulness of these particular tools after they see how the estimates match up with consumers’ actual experiences.
- Provider information: Federal rules require insurers that participate in marketplaces to provide direct links to each plan’s directory of in-network providers and facilities. In addition, some marketplaces including healthcare.gov allow consumers and assisters to search across plans to determine what plans include a specific provider or facility. Some marketplace websites also prominently display, such as via a search tool, whether the plan is an HMO, EPO, POS, or PPO – while other marketplaces use only the name of the plan to indicate the type. Furthermore, there is no standard definition for what counts as a PPO, HMO, or other type of network design in most states. Most assisters (84 percent) in marketplaces with provider search features found them useful when helping clients with plan selection. However, many assisters, when asked what they would like to see in plan selection tools, noted problems with the accuracy of provider directories, and several mentioned that consumers needed more information about the meaning of various plan types (EPO, PPO, etc.). In addition to provider directory issues, 60 percent of assisters who talked with clients about the ability to access in-network providers stated it was difficult or somewhat difficult for clients to access the types of in-network providers they seek. This speaks to the need for implementation and enforcement of network adequacy standards.
Marketplace websites can be improved in the following ways to better meet the needs of consumers:
- Make it easy to find the new “simple choice” plans that will offer most outpatient services before the deductible is met in 2017; in all plans, make it possible to consistently determine what services are offered pre-deductible, both when sorting plans by deductible level and when comparing plans. In 2017, for the first time, the federal marketplace is encouraging issuers to offer “simple choice plans” – standardized plans that will offer most outpatient care pre-deductible. We recommend that the healthcare.gov feature these plans prominently, making it easy to search for them. In all marketplaces, we recommend that websites make it easy to identify plans that cover services, in addition to preventive care, before the deductible is met.Most assisters use a tool on marketplace websites to search plans by deductible level. Given this, the display should immediately note which of the plans offer services, in addition to preventive care, before the deductible is met, including both simple choice plans and other plans that offer pre-deductible services. Without a prominent icon or some other indicator that there are pre-deductible services, the size of the deductible is misleading.Even assisters who are not sorting plans by deductible still view information about the size of each plan’s deductible on marketplace websites. For example, on healthcare.gov, a blue box under each plan name lists the overall deductible – and we strongly recommend that this box indicate whether there is coverage of some services, in addition to preventive care, before the deductible is met. For instance, the box could be color coded differently for plans offering pre-deductible coverage of some services.Further, consumers and assisters should readily be able to find out what specific services are pre-deductible without pulling up each plan’s documents. The blue box on the federal website would be a logical place to list any services offered before a deductible is met, and state marketplaces should find similar prominent places to list such services.
- Provide a search engine, similar to that used in Medicare Part D, which allows consumers to search across plans for a drug and the cost to the consumer of that drug. This year, healthcare.gov tested a tool that allows consumers to enter their drugs and determine which plans do and do not cover them. While this is a helpful start, assisters and consumers would also like to easily be able to find and compare what tier of coverage the drug is on in each plan, and what copayments or coinsurance apply. For 2016, federal rules require plan formularies to list the tier on which a drug is covered, but then consumers and assisters may have to turn to another document, the plan’s summary of benefits and coverage, to determine what copay or coinsurance amount applies to a given tier. Assisters and consumers should have integrated information that tells both the tier of coverage for a drug and what copayment or coinsurance amount applies.Further, when drugs are subject to coinsurance, there is currently no easy way to find out what that drug might cost a consumer. Marketplaces should provide an estimate of the dollar amount of coinsurance a consumer will face for drugs to which coinsurance applies. Texas is an example of a state that already requires insurers to provide information in their formularies about the dollar amount of coinsurance a consumer will pay for a drug.Beginning in 2017, insurers must establish Pharmacy & Therapeutic committees made up of medical professionals that will provide stricter oversight of changes in drug formularies. Consumer groups advocate that mid-year changes in formularies should be prohibited except in very limited circumstances. When formularies do change, plans and marketplaces should promptly update information on the marketplace website.
- Provide direct links to more specific information about medical management programs: Medical management programs can range from telephonic coaching alone to the provision of medical supplies, drugs and services at low out-of-pocket costs plus support groups and coaching to manage a condition. Federal and state marketplaces should set some standards for what can be considered a medical management program. Plans that list medical management programs among their services should be required to provide specific information in an easily linkable document about what that program entails. Marketplace websites that display a list of plans with medical management programs should link to plan information that provides the specific details.
- Enhance ability to estimate total costs: Features allowing consumers to estimate their total costs in plans, including premiums plus what they will likely pay for care given different medical use scenarios, are still in their infancy and our survey results indicate they have not yet been widely used by assisters. Even in marketplaces without these tools, some assisters suggest that they would better be able to help consumers determine their costs if they could combine several features into one sort, such as deductibles plus premiums plus plan type. They also would like to be able to compare costs in plans for a few specific medical scenarios in order to better gauge what a consumer might pay after an unforeseen medical event. Summaries of benefits and coverage will include more of these examples beginning in the spring of 2017 and marketplace websites should facilitate comparisons of these coverage examples. However, since pricing for these coverage examples is not specific to a geographic location, information should also be provided about how to determine the specific out-of-pocket costs a consumer might face if they see providers in their plan for a procedure.
- Improve information about provider networks: When asked what they would like to see in plan selection tools, many assisters note inaccuracies in information about what providers are in plan networks. Some states require that plans regularly audit their directories for accuracy, hold consumers harmless when they visit out-of-network providers listed as in-network, and make it easy for the public to report inaccuracies so that the plans can correct them. These policies should be required nationwide. Inaccuracies in provider directories may help explain the significant share of assisters who reported consumer problems obtaining access to in-network care, as provider directory inaccuracies may mask problems with network adequacy. In addition to provider directory requirements, nationwide network adequacy standards, such as time and distance standards and appointment wait time standards, should be enacted to ensure sufficient access to care in marketplace plans.Assisters also want to be able to search for providers in a plan that speak a given language. Some states require provider directories to include information about languages spoken. We recommend that this be required in all states and in the federal marketplace.Finally, assisters note that the meaning of plan types, such as EPOs (Exclusive Provider Organizations) are not widely understood and they want tools to better explain plan types to consumers. State legislatures and insurance commissioners should ensure that plan types are consistently defined in their laws and regulations, and exchange directors should then provide educational materials on marketplace websites to help assisters and consumers understand what network restrictions apply to various types of plans.
Families USA, with Davis Research, conducted an online survey of 655 enrollment assisters in April 2016. Responses were drawn from Families USA’s network of thousands of assisters across the country. The typical assister responding to the survey had enrolled 130 people in coverage. Data were weighted to reflect the distribution of assisters by marketplace type (federal marketplace or state marketplace). In some of the statistics in this analysis, we excluded assisters who answered that the question was not applicable. The response number was at least 318 in all statistics reported here.