COMMITTEE ROLL CALL Jessica Altman, Chair Pennsylvania

Date: 4/6/19

2019 Spring National Meeting Orlando, Florida

HEALTH INSURANCE AND MANAGED CARE (B) COMMITTEE Sunday, April 7, 2019 3:30 – 5:30 p.m. Ritz-Carlton Orlando—Ballroom Salons 1–3—Lobby Level

ROLL CALL

Jessica Altman, Chair Pennsylvania John Elias New Hampshire Lori K. Wing-Heier, Vice Chair Alaska Linda Lacewell New York Michael Conway Colorado Jon Godfread North Dakota Dean L. Cameron Idaho Andrew Stolfi Oregon Vicki Schmidt Kansas Julie Mix McPeak Tennessee Nancy G. Atkins Kentucky Scott A. White Virginia Steve Kelley Minnesota Mike Kreidler Washington Mike Chaney Mississippi

NAIC Support Staff: Jolie H. Matthews/Brian R. Webb/Jennifer R. Cook

AGENDA

1. Consider Adoption of its Feb. 14, 2019, and 2018 Fall National Meeting Minutes —Commissioner Jessica Altman (PA)

2. Consider Adoption of the Regulatory Framework (B) Task Force Report and the Request for NAIC Model Law Development—Commissioner Michael Conway (CO)

2A. Consider Adoption of its Subgroup, Working Group and Task Force Reports —Commissioner Jessica Altman (PA) • Consumer Information (B) Subgroup—Angela Nelson (MO) • Health Innovations (B) Working Group—Health Insurance Commissioner Marie L. Ganim (RI) • Health Actuarial (B) Task Force—Director Anita G. Fox (MI) and Kevin Dyke (MI) • Long-Term Care Insurance Joint (B/E) Task Force—Commissioner Jessica Altman (PA) and Commissioner David Altmaier (FL) • Senior Issues (B) Task Force—Director Lori K. Wing-Heier (AK)

3. Hear a Panel Presentation on Health Care Cost Data—Kim Holland (Blue Cross and Blue Shield Association—BCBSA), Kevin Kennedy (Health Care Cost Institute—HCCI) and Maureen A. Mustard (NH)

4. Hear an Update on Legal Action Surrounding the Federal Affordable Care Act (ACA) —William G. Schiffbauer (Law Office of William G. Schiffbauer, Chartered)

5. Hear Results of Consumer Testing Related to a Short-Term, Limited-Duration Plan (STLDP) —Katie Keith (Out2Enroll) and Susan Kleimann (Kleimann Communication Group)

6. Hear a Federal Legislative Update—Joseph Touschner (NAIC)

7. Discuss the Federal Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and Next Steps for Future Discussions of the MHPAEA—Commissioner Jessica Altman (PA)

8. Discuss Any Other Matters Brought Before the Committee—Commissioner Jessica Altman (PA)

9. Adjournment

W:\National Meetings\2019\Spring\Agenda\B Cmterev1.docx

Agenda Item #1

Consider Adoption of its Feb. 14, 2019 and 2018 Fall National Meeting Minutes —Commissioner Jessica Altman (PA) Attachment One Health Insurance and Managed Care (B) Committee 4/--/19

Draft: 3/11/19

Health Insurance and Managed Care (B) Committee Conference Call February 14, 2019

The Health Insurance and Managed Care (B) Committee met via conference call Feb. 14, 2019. The following Committee members participated: Jessica Altman, Chair (PA); Lori K. Wing-Heier, Vice Chair (AK); Michael Conway (CO); Dean L. Cameron (ID); Vicki Schmidt (KS); Nancy G. Atkins (KY); Steve Kelley represented by Kristi Bohn and Fred Andersen (MN); Mike Chaney represented by Bob Williams (MS); Jon Godfread (ND); John Elias represented by Jennifer Patterson (NH); Linda Lacewell represented by Troy Oechsner (NY); Andrew Stolfi (OR); Julie Mix McPeak (TN); Scott A. White (VA); and Mike Kreidler represented by Jane Beyer and Molly Nollette (WA). Also participating were: Robert Wake (ME); Kevin Dyke (MI); and Martin Swanson (NE).

1. Adopted Revisions to the Compliance Manual

Mr. Dyke said the Health Actuarial (B) Task Force received a referral in 2017 from the Senior Issues (B) Task Force to consider revisions to the NAIC Medicare Supplement Insurance Model Regulation Compliance Manual (Compliance Manual) related to the federal Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). He said the Health Actuarial (B) Task Force began discussion of the revisions at the 2017 Summer National Meeting. He described the Task Force’s drafting process ending with its adoption of the revisions during a Jan. 10 conference call.

Director Wing-Heier made a motion, seconded by Director Cameron, to adopt the revisions to the Compliance Manual (see NAIC Proceedings – Spring 2019, Executive (EX) Committee and Plenary, Attachment ____). The motion passed unanimously.

2. Adopted Revisions to the ERISA Handbook

Mr. Wake said the ERISA (B) Working Group discussed the revisions to the Health and Welfare Plans Under the Retirement Income Security Act: Guidelines for State and Federal Regulation (ERISA Handbook) during several conference calls throughout 2018. He said the proposed revisions to the ERISA Handbook include several important updates since its last revision in 2004. Mr. Wake said those revisions include updates to case law, as well as new sections related to the federal Affordable Care Act (ACA) and the recently finalized federal regulations on association health plans (AHPs). He said the Working Group adopted the revisions via an e-vote that concluded Nov. 1, 2018, and the Regulatory Framework (B) Task Force adopted the revisions at the 2018 Fall National Meeting.

Ms. Patterson made a motion, seconded by Director Cameron, to adopt the revisions to the ERISA Handbook (see NAIC Proceedings – Spring 2019, Executive (EX) Committee and Plenary, Attachment ____). The motion passed unanimously.

3. Adopted Revisions to Model #170

Commissioner Conway said the Regulatory Framework (B) Task Force adopted revisions to the Accident and Sickness Insurance Minimum Standards Model Act (#170), including changing the title to the Supplementary and Short-Term Health Insurance Minimum Standards Model Act, at the 2018 Fall National Meeting. He said the revisions remove provisions in the model concerning the types of health benefit plans subject to the ACA’s requirements, and they leave remaining in the model those types of plans that are not subject to the ACA’s requirements.

Commissioner Conway said the revisions reflect the Accident and Sickness Insurance Minimum Standards (B) Subgroup’s almost year-long, extensive discussion and debate of myriad issues, such as the model’s title, scope and purpose. The main issues the Subgroup discussed were providing flexibility to the states with respect to the regulation of short-term, limited- duration (STLD) plans and what information to include in consumer disclosures for these types of plans, such that consumers are aware of what type of plan they are purchasing prior to purchase. Commissioner Conway said that because this is a model act, at least two-thirds of the Committee members must vote in favor of the revisions for them to be adopted.

Commissioner Conway made a motion, seconded by Ms. Bohn, to adopt the revisions to Model #170 (see NAIC Proceedings – Spring 2019, Executive (EX) Committee and Plenary, Attachment ____).

Director Cameron asked why the Subgroup included STLD plans in the revised model, because such plans are not excepted benefits as the other coverages in the revised model. Jolie Matthews (NAIC) explained that the Subgroup decided to include STLD plans in the revised model because there were no other NAIC models in which to include the coverage. In addition, she explained that the Subgroup wanted to provide guidance to the states for such plans as expeditiously as possible, because if the Subgroup had decided to develop a new NAIC model, then it would have taken at least a year to complete the work. Mr. Swanson agreed with Ms. Matthews. Mr. Wake also explained the Subgroup’s reasoning for including STLD plans in the revised model, supporting Ms. Matthews’ comments.

Director Cameron asked if the states are required to adopt Model #170 to satisfy the NAIC’s accreditation standards. Ms. Matthews said Model #170 is not an accreditation standard.

The motion passed unanimously, with Alaska, Colorado, Idaho, Kansas, Kentucky, Minnesota, Mississippi, New Hampshire, New York, North Dakota, Oregon, Pennsylvania, Tennessee, Virginia and Washington voting in favor of the motion (i.e., more than the requisite number of Committee members needed for adoption).

4. Adopted Revisions to the Shopper’s Guide

Director Wing-Heier said the Senior Issues (B) Task Force adopted revisions to the Shopper’s Guide to Long-Term Care Insurance (Shopper’s Guide) during its Oct. 29, 2018, conference call. She noted that the Long-Term Care Shopper’s Guide (B) Working Group adopted the revisions during its Oct. 15, 2018, conference call, after working on the revisions throughout 2018. She said the revisions delete obsolete language and update out-of-date language. The revisions also streamline language, shortening the Shopper’s Guide’s length.

Commissioner Conway made a motion, seconded by Commissioner Godfread, to adopt the revisions to the Shopper’s Guide (see NAIC Proceedings – see NAIC Proceedings – Spring 2019, Executive (EX) Committee and Plenary, Attachment ____). The motion passed unanimously.

5. Adopted the Regulatory Framework (B) Task Force’s Recommendation to Open Model #430 for Revision in Response to the Receivership and Insolvency (E) Task Force’s Referral to the Committee

Commissioner Conway said the Committee received a referral in May 2018 from the Receivership and Insolvency (E) Task Force to perform a review of relevant health maintenance organization (HMO) model laws to determine if conforming changes are needed to provide options for the states that have enacted or are enacting the recently revised Life and Health Insurance Guaranty Association Model Act (#520). He explained that the revisions to Model #520 added HMOs as members of the life and health insurance guaranty association.

Commissioner Conway said the Committee accepted the referral and charged the Regulatory Framework (B) Task Force with conducting the requested review and reporting back to Committee with its recommendation. The Task Force established the HMO Issues (B) Subgroup to carry out the review and report back to the Task Force with its recommendation. He said the Subgroup met via conference call two times. During these conference calls, the Subgroup identified conflicts and redundancies between Model #520 and the Health Maintenance Organization Model Act (#430).

Commissioner Conway said the Subgroup submitted its report to the Task Force at the 2018 Fall National Meeting, noting that it recommended opening Model #430 for revisions to resolve the identified conflicts. He said the Task Force adopted the Subgroup’s recommendation. However, in adopting the recommendation, the Task Force chose not to provide guidance on whether Model #430 should be opened for revision in its entirety or only for those areas of specific conflict. Commissioner Conway said the Task Force sent this recommendation to the Committee for its consideration.

Commissioner Altman requested comments. Ms. Nollette said Washington does not oppose opening Model #430 for revision, but the revisions should provide flexibility for those states not planning to adopt the Model #520 revisions.

Bob Ridgeway (America’s Health Insurance Plans—AHIP) reiterated AHIP’s position that opening Model #430 is not necessary, and it is premature at best. He noted that the revisions to Model #520 have been adopted by some states, but not all states. He also noted that HMOs do not fully operate like insurers. He said AHIP recommends waiting until the NAIC knows what the states plan to do with respect to the Model #520 revisions before opening Model #430.

Chris Petersen (Arbor Strategies) expressed concern with opening Model #430 if the scope of the revisions is going to include consideration of revisions not related to those provisions in conflict with Model #520.

David Link (Kaiser Permanente—Kaiser) reiterated Kaiser’s comments from previous discussions related to opening Model #430. He said if Model #430 is opened, the Task Force should only consider revisions to provisions in Model #430 that conflict with Model #520.

Commissioner Conway made a motion, seconded by Director Wing-Heier, to adopt the Task Force’s recommendation to open Model #430. The motion passed unanimously.

6. Disbanded the Health Care Reform Regulatory Alternatives (B) Working Group and Appointed the Health Innovations (B) Working Group

Brian Webb (NAIC) said the Health Care Reform Regulatory Alternatives (B) Working Group was appointed soon after the enactment of the ACA. He said the Working Group was appointed to act as a forum for state insurance regulators to consider and discuss the states’ alternative approaches to implementing certain ACA provisions, such as through the ACA’s Section 1332 waiver process. He said that since the Working Group’s appointment, things have changed such that the Committee should consider appointing a new group with a broader scope to allow it to consider other state alternatives and innovations in addition to the ACA Section 1332 innovative waiver option, such as different state innovations to address increasing health care costs. The Committee expressed support for disbanding the Working Group and appointing the Health Innovations (B) Working Group.

Ms. Patterson made a motion, seconded by Director Cameron, to disband the Health Care Reform Regulatory Alternatives (B) Working Group and appoint the Health Innovations (B) Working Group. The motion passed unanimously.

7. Disbanded the CO-OP Solvency and Receivership (B) Subgroup

Mr. Webb said the CO-OP Solvency and Receivership (B) Subgroup was appointed in 2016 to provide a forum for state insurance regulators to discuss and share information through conference calls and meetings on the status of the Consumer Operated and Oriented Plans (CO-OPs) created under the ACA. He said when the Subgroup was first appointed, the Subgroup met almost monthly via conference call in regulator-to-regulator session to discuss the status of the existing CO-OPs. The Subgroup also met at the national meetings. Mr. Webb explained that as the number of operational CO-OPs has decreased, the Subgroup has been meeting quarterly via conference call in regulator-to-regulator sessions. Mr. Webb said, currently, because there are few existing operational CO-OPs, he suggests the Committee consider disbanding the Subgroup and carrying out the Subgroup’s work through the Committee on a less formal basis. The Committee expressed support for Mr. Webb’s suggestion.

Commissioner Atkins made a motion, seconded by Commissioner Stolfi, to disband the CO-OP Solvency and Receivership (B) Subgroup. The motion passed unanimously.

Having no further business, the Health Insurance and Managed Care (B) Committee adjourned.

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Draft: 11/28/18

Health Insurance and Managed Care (B) Committee San Francisco, California November 16, 2018

The Health Insurance and Managed Care (B) Committee met in San Francisco, CA, Nov. 16, 2018. The following Committee members participated: Dean L. Cameron, Chair, and Weston Trexler (ID); Jessica Altman, Vice Chair (PA); Lori K. Wing- Heier (AK); Nancy G. Atkins (KY); Jessica Looman (MN); Mike Chaney represented by Bob Williams (MS); John Elias represented by Jennifer Patterson (NH); Mike Causey represented by Ted Hamby (NC); Larry Deiter (SD); Todd E. Kiser and Tanji Northrup (UT); Mike Kreidler and Molly Nollette (WA); and Ted Nickel represented by J.P. Wieske (WI). Also participating were: Ryan James (AR); Dave Jones and Perry Kupferman (CA); Michael Conway (CO); Karl Knable (IN); Ken Selzer (KS); Kevin Dyke (MI); Paige Duhamel (NM); Maria T. Vullo and Troy Oechsner (NY); Kelly Dexter (OK); Andrew Stolfi (OR); and Marie Ganim (RI).

1. Adopted its Oct. 24, Oct. 2 and Summer National Meeting Minutes

The Committee met Oct. 24, Oct. 2 and Aug. 5. During its Oct. 24 meeting, the Committee adopted its 2019 proposed charges and those of its task forces. During its Oct. 2 meeting, the Committee: 1) adopted the Limited Long-Term Care Insurance Model Act and the Limited Long-Term Care Insurance Model Regulation; and 2) adopted a request to extend the time to develop amendments to the Health Insurance Reserves Model Regulation (#10) to reflect appropriate long-term care insurance (LTCI) standards.

Director Wing-Heier made a motion, seconded by Commissioner Atkins, to adopt the Committee’s Oct. 24 (Attachment One), Oct. 2 (Attachment Two) and Aug. 5 (see NAIC Proceedings – Summer 2018, Health Insurance and Managed Care (B) Committee) minutes. The motion passed unanimously.

2. Adopted its Subgroup, Working Group and Task Force Reports

a. Consumer Information (B) Subgroup

The Subgroup met Oct. 30, Oct. 19, Oct. 5, Oct. 1, Sept. 21, Sept. 14 and Sept. 7 via conference call. During these meetings, the Subgroup took the following action: 1) developed and adopted a Health Coverage Shopping Tool; and 2) revised and adopted the Frequently Asked Questions about Health Care Reform.

b. CO-OP Solvency and Receivership (b) Subgroup

The Subgroup met Sept. 19 via conference call, in regulator-to-regulator session pursuant to paragraph 3 (specific companies, entities or individuals) of the NAIC Policy Statement on Open Meetings, to receive updates from impacted states on Consumer Operated and Oriented Plan (CO-OP) receiverships and lawsuits.

c. Health Care Reform Regulatory Alternatives (B) Working Group

The Working Group met Nov. 15 and took the following action: 1) adopted its Summer National Meeting minutes; 2) discussed revised guidance from the U.S. Department of Health and Human Services and the U.S. Department of the Treasury on Section 1332 waivers; 3) discussed state alternatives to using the federal exchange platform; 4) heard a presentation from Manatt Health Solutions on strategies to expand transparency and enhance competition; and 5) discussed the concerns of consumer representatives regarding the revised Section 1332 guidance, short-term health plans and enhanced direct enrollment.

d. Health Actuarial (B) Task Force

The Task Force met Nov. 14 and took the following action: 1) adopted its Oct. 18, Sept. 25, Sept. 11 and Summer National Meeting minutes; 2) adopted the reports of the Health Care Reform Actuarial (B) Working Group, the Long-Term Care Actuarial (B) Working Group, the Long-Term Care Valuation (B) Subgroup, the Long-Term Care Pricing (B) Subgroup and the Long-Term Actuarial (B) Working Group; 3) heard an update from the American Academy of Actuaries (Academy) Council on Professionalism and the Academy Health Practice Council; 4) heard updates from the Society of Actuaries (SOA) on health insurance research and group life waiver of premium results; and 5) agreed to expose, for a 30-day public comment period,

© 2018 National Association of Insurance Commissioners 2 Draft Pending Adoption draft changes to the Medicare Supplement Insurance Model Regulation Compliance Manual necessitated by the federal Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

e. Regulatory Framework (B) Task Force

The Task Force met Nov. 15 and took the following action: 1) adopted its Oct. 17, Sept 24. and Summer National Meeting minutes; 2) adopted the Oct. 17 revisions to the Accident and Sickness Insurance Minimum Standards Model Act (#170); 3) heard an update from the Center on Health Insurance Reforms on its work related to the federal Affordable Care Act (ACA); 4) heard a presentation on rehabilitative and habilitative services and devices for speech language and hearing from the American Speech-Language-Hearing Association; 5) heard a presentation from Quest Analytics on network adequacy and provider data accuracy; 6) adopted the reports of the Accident and Sickness Insurance Minimum Standards (B) Subgroup, the HMO Issues (B) Subgroup, the Pharmacy Benefit Manager Regulatory Issues (B) Subgroup and the ERISA (B) Working Group; and 7) adopted the Nov. 1 revisions to the Health and Welfare Plans Under the Employee Retirement Income Security Act: Guidelines for State and Federal Regulation, as submitted by the ERISA (B) Working Group.

f. Senior Issues (B) Task Force

The Task Force met Nov. 15 and took the following action: 1) adopted its Oct. 29, Oct. 12 and Summer National Meeting minutes; 2) adopted the report of the Long-Term Care Shopper’s Guide (B) Working Group; 3) heard an update on federal legislative matters; and 4) heard a presentation from AARP on issues seniors may be facing in the future.

Mr. Williams made a motion, seconded by Mr. Wieske, to adopt the Committee’s subgroup, working group and task force reports: the Consumer Information (B) Subgroup, including its Oct. 30 (Attachment Three), Oct. 19 (Attachment Four), Oct. 5 (Attachment Five), Oct. 1 (Attachment Six), Sept. 21 (Attachment Seven), Sept. 14 (Attachment Eight), and Sept. 7 (Attachment Nine) minutes; the CO-OP Solvency and Receivership (B) Subgroup; the Health Care Reform Regulatory Alternatives (B) Working Group (Attachment Ten); the Health Actuarial (B) Task Force; the Regulatory Framework (B) Task Force; and the Senior Issues (B) Task Force. The motion passed unanimously.

3. Heard a Presentation on the Status of the Individual Insurance Market

Randy Pate (Center for Consumer Information and Insurance Oversight—CCIIO) described the current individual market, from a national perspective, as more stable with lower premium increases overall and more carriers participating in the market. Mr. Pate also discussed the new Section 1332 waiver guidance that was issued by the CCIIO, which is intended to make the waiver process less cumbersome and more flexible. Mr. Pate noted that the CCIIO is in the process of developing templates that will provide examples of innovative waivers it would be willing to consider.

Director Cameron asked whether there are certain areas of innovation the CCIIO would be willing to consider, or if there any waivers that have been denied that would now be approved. Mr. Pate responded that the new guidance was built on lessons learned from past waiver applications, noting that the CCIIO is hopeful that the upcoming templates and examples will begin further discussions with the states.

Director Cameron noted that increasing the number of carriers participating in the individual market should increase competition and drive premiums down. However, some say that association health plans (AHPs) and short-term, limited- duration (STLD) plans work contrary to that goal. He asked Mr. Pate his view on this issue. Mr. Pate said that both the AHP and STLD regulations focus on state flexibility, noting that states have the option whether to allow them and how to regulate them. This allows the states to do what is best to find the balance between all these issues.

Director Wing-Heier requested that the CCIIO provide information to the states seeking a waiver on how federal funding is distributed after the waiver is approved. Mr. Pate agreed that this would be a good idea, noting that this could be included in additional guidance that may also include more federal platform flexibility, such as tax credit alternatives.

Superintendent Vullo asked whether AHPs and STLD plans are at the discretion of the states. Mr. Pate agreed that the states may decide whether and under what regulations AHPs and STLD plans may sell products to individual and small employers in their jurisdiction. Superintendent Vullo asked whether the CCIIO has data on how many individuals did not have coverage before the ACA was enacted. Mr. Pate said he was not aware of such a study at the CCIIO.

Jack Resneck (American Medical Association—AMA) discussed the impact of preauthorization requirements on the cost of health care delivery, providing examples from his own dermatology practice on how routine prescriptions can require hours of work to gain preauthorization. This leads to less efficient care, higher costs, and patient and physician frustration. Mr. Resneck also expressed the need for accurate information on providers participating in networks and greater network adequacy oversight, as well as the need to protect consumers to go to in-network facilities but receive care from out-of-network providers.

Commissioner Selzer asked whether the ACA aggravated these issues. Mr. Resneck noted that these issues existed well before the ACA and still occur in off-exchange plans.

Commissioner Kreidler recommended that providers contact their state insurance department if they have a preauthorization problem, because many states have laws that address this issue. He also noted that some consumers choose narrower networks, but still need to be protected. Mr. Resneck agreed and said consumers need accurate information about the carrier’s network, as well as clear and timely disclosures regarding any mid-plan year changes to the network. He added that mid-plan year formulary changes are a growing problem. Ms. Duhamel echoed Commissioner Kreidler’s recommendation that physicians should contact their state insurance department and file a complaint if there is a problem. This would help the states regulate the carriers.

Ms. Ganim said Rhode Island is performing a market conduct exam on prior authorization and asked if Mr. Resneck’s research focused just on prescription drugs. Mr. Resneck said his research was not limited to prescription drugs.

Ms. Patterson noted that New Hampshire has been able to develop good data regarding network adequacy through the state’s all-claims database and asked if Mr. Resneck was familiar with the state’s work. Mr. Resneck said he was not aware of it but would look into it.

Mr. Oechsner discussed New York’s surprise bill law, which takes the consumer out of the equation but, of course, leads to a dispute between the provider and the carrier. He encouraged the AMA to work with the states to determine a reasonable method for resolving these disputes. Mr. Oechsner also asked if Mr. Resneck had a position on price transparency. Mr. Resneck responded that he likes it. He noted that physicians need access to information on a patient’s choices and the costs of those choices when they are working with the patient.

Commissioner Selzer asked what the roadblock is to achieving transparency. Mr. Resneck posited that it is the prescription drug companies, among others.

5. Heard a Briefing on State Legislative and Administrative Actions to Address Prescription Cost-Sharing

Carl Schmid (The AIDS Institute) briefed the Committee on the need for state actions to protect consumers from high prescription drug cost-sharing requirements. He noted that higher cost-sharing requirements lead to delays in care or forgoing of care, which often leads to higher medical costs down the road. He also described some discriminatory practices by carriers that create higher cost-sharing obligations on certain populations that can afford it least.

Mr. Schmid provided an overview of state legislative actions that limit cost-sharing and regulatory actions against discriminatory practices and encouraged Committee members to support such activities in their states.

6. Heard a Panel Presentation on Direct Primary Care Arrangements

Julie Gunther (Direct Primary Care Coalition) and Clint Flanagan (Direct Primary Care Coalition) provided information on how direct primary care arrangements work and how they can impact care and costs. Both practicing primary care physicians noted that the direct primary care arrangement allows them to focus on their patients and their care, rather than submitting paperwork, securing preauthorization and meeting carrier requirements. By receiving a flat monthly fee, the physician is able to spend more time with each patient, instead of making sure they see enough patients each day to ensure they receive enough reimbursement. They noted that direct primary care physicians also have more control over the type of care provided and have more time to provide more extensive services.

Mr. Flanagan said a growing number of self-funded plans are using a portion of their premium dollars to pay for direct primary care arrangements for their members and this has led to lower overall health care costs due to better primary care. Mr. Gunther also noted that these arrangements lead to higher physician gratification and patient contentment.

© 2018 National Association of Insurance Commissioners 4 Draft Pending Adoption Commissioner Selzer asked how many participants in these direct primary care arrangements also have health insurance coverage for other medical needs. Mr. Flanagan responded that 95% to 97% have some kind of coverage in addition to this arrangement, noting that a few participate in health-sharing ministries.

Director Wing-Heier asked what services are included as “primary” in these arrangements. Mr. Gunther noted that more than 90% of medical needs can be addressed by a primary care physician, which leads to less need for referral. Additional care may be needed for some tests, major injuries or specialty needs.

Commissioner Altman asked whether capacity is an issue with these kinds of arrangements. Mr. Gunther and Mr. Flanagan both noted that payments are made month-to-month. If a physician is unable to provide adequate care, then the patient will stop making the payments. This leads to the market setting the appropriate number of patients, and the mix of patients. Mr. Gunther added that each physician knows when they reach their capacity and it is not set by a carrier.

Director Cameron asked whether the panelists saw a disconnect between the ACA’s primary care mandate and the direct primary care model. He also asked if there is a way for ACA-compliant plans in the small group and individual markets to use direct primary care in combination with other coverage. Mr. Flanagan noted that self-funded plans are doing this now. It is possible to do this with fully insured plans, but there may need to be refinements to the ACA to make the wrap-around coverage compliant.

7. Heard a Panel Presentation on Health Care Sharing Ministries

JoAnn Volk (Georgetown University, Center on Health Insurance Reforms—CHIR) presented CHIR’s findings on health care sharing ministries and state-based regulation of these arrangements. Brad Hahn (Solidarity HealthShare) provided information on Solidarity HealthShare, a Catholic health care sharing ministry.

Ms. Volk highlighted the limitations of health care sharing ministries: less benefits; unsure reimbursement; limited regulation; and consumer protections. Mr. Hahn noted that Solidarity HealthShare provides extensive benefits, and has even expanded benefits as needs have arisen, and work closely with providers to keep costs down for members and the plan. He also said Solidarity HealthShare provides an important option for people who have a conscious objection to some services covered by other plans.

8. Heard a Presentation on State-Based Regulation of Non-ACA Compliant Plans

Ms. Volk provided a summary of a recent CHIR paper: “State Regulation of Coverage Options Outside of the Affordable Care Act: Limiting Risk to the Individual Market.” The paper focused on the state-based regulation of AHPs, STLD plans, and health care sharing ministries and found that state-based regulation varies greatly. Some states ban self-funded AHPs and STLD plans, while others apply solvency requirements, consumer protections, time limits or other restrictions on these plans. Even the regulation of fully insured AHPs varies from state-to-state. Very few states regulate health care sharing ministries.

Director Wing-Heier asked whether there is any data on new AHPs formed under the new federal regulations. Ms. Volk was not aware of such a list. Director Cameron asked if this research will continue and look at the impact of these other coverage options on the insurance markets. Ms. Volk said the research will be updated to look at the impact of these plans.

Superintendent Vullo asked whether the information on various state approaches to the regulation of STLD plans will be publicized. Ms. Volk responded that the report will include state-by-state information.

Commissioner Selzer asked whether there are fewer uninsured due to the expansion of AHPs and STLD plans. Ms. Volk said the impact is unclear and would depend on the definition of “coverage.”

9. Heard a Panel Presentation on AHPs

Christopher Condeluci (Coalition to Protect and Promote AHPs) talked about the flexibility created by the new federal regulations that allow associations of small employers to be treated like a large employer, and even include sole proprietors. He outlined the advantages he saw in allowing associations to develop plans that meet the needs of small employers, reduce premiums and provide economies of scale. He raised concerns about the states that are resisting the new pathway for associations to form and offered to work with the states to demonstrate how these AHPs can benefit employers and their employees.

© 2018 National Association of Insurance Commissioners 5 Draft Pending Adoption Clinton Wolf (Restaurant & Hospitality Association Benefit Trust—R&HA Trust) described the new AHP developed by the National Restaurant Association (NRA) under the old AHP pathway to provide coverage for its underserved members. He discussed the history of the NRA’s provision of coverage options to its members and how the new multistate AHP, which meets the requirements of all states in which it operates, is an extension of this effort. He listed the benefits provided to enrollees and talked about how rates are established.

David Chase (Small Business Majority) expressed concern about AHPs, which have historically provided inferior benefits and consumer protections and often failed. He raised objections to the new federal regulation and encouraged state insurance regulators to protect small businesses by regulating AHPs in their states.

Commissioner Kreidler asked if all small businesses that join an AHP are treated the same for underwriting and rating. Mr. Condeluci noted that, under the new pathway, discrimination based on health status is not allowed. However, under the existing pathway, AHPs can underwrite and set rates based on health status.

Commissioner Kreidler asked Mr. Wolf if the R&HA Trust plan covers organ donors. Mr. Wolf said it does. Commissioner Kreidler also asked if the plan underwrites its members based on health status. Mr. Wolf said it does, because the plan is built to last 50 years.

Ms. Northrup asked how premiums are reduced if the benefits are just as robust and there is no underwriting under the new pathway. Mr. Condeluci noted that in some states with a healthy small group market, like Utah, these plans may not be needed. Before one is established, there is extensive market research and price comparison.

Mr. Wieske noted that there is interest in AHPs in Wisconsin due to troubles in the small group and individual markets, but there are some concerns at the insurance department due to past issues. The state does not allow self-funded AHPs and regulators are looking at how fully insured plans are regulated.

Director Cameron raised his concern that AHPs, in the past, have not lasted. They have been picked apart as healthier members have left. He asked if there is a strategy for addressing this. Mr. Condeluci said experience rating, as has been discussed earlier, certainly helps keep the plans solvent.

10. Heard a Presentation on Legal Actions Surrounding the ACA

William Schiffbauer (Law Office of William G. Schiffbauer) gave an overview of three important cases involving the ACA: 1) Texas v. USA, which challenges the constitutionality of the ACA’s individual mandate; 2) State of New York v. U.S. Department of Labor, which challenges the legality of the federal AHP regulation; and 3) ACAP v. U.S. Department of Treasury, which challenges the legality of the federal STLD plan regulation.

Mr. Schiffbauer said the Texas v. USA case could have its first decision any day now and could have significant ramifications. The plaintiffs argue that because the individual mandate penalty has been eliminated by the U.S. Congress, then the individual mandate is unconstitutional. The biggest question is whether the judge, if he agrees that it is unconstitutional, rule that the guaranteed issue and rating rules in the ACA are also unconstitutional, or even that the whole law is unconstitutional. There is also the question as to whether the ruling would only apply in the states that joined in the suit. No matter this first ruling, it was noted by Mr. Schiffbauer that it will certainly be appealed, and an injunction granted against any action during that appeal.

Mr. Schiffbauer walked through the key arguments and the timeline for the other two cases, as well.

Director Cameron asked whether the fact that the U.S. Department of Justice says the individual mandate is unconstitutional mean it will not be implemented if the court finds it unconstitutional. Mr. Schiffbauer doubted that would be case, given the disruption it would cause.

11. Discussed Various State Responses to Recent Federal Actions

Director Cameron asked Committee members to provide information on their states’ actions in response to the recent STLD plan regulation.

Director Wing-Heier said Alaska will be looking at the impact of these plans over time. Alaska has 79 STLD plans and is concerned about consumers who may purchase one not understanding its limitations. However, Alaska believes the sick and subsidized population will remain in the ACA market.

© 2018 National Association of Insurance Commissioners 6 Draft Pending Adoption Mr. Wieske noted that during Wisconsin’s Section 1332 waiver analysis, it found the individual market to be very price elastic. With rates declining due to the new reinsurance program, Wisconsin does not expect much impact at this time.

Director Cameron said there has been no major uptick in STLD plan enrollment in Idaho, and he noted that the only limitation on STLD plans Idaho has in statute is they cannot be renewable.

Ms. Nollette said Washington issued new regulations on STLD plans, noting that a recent market study showed these plans are truly used as gap coverage.

Director Cameron asked Committee members if their states have enacted new rules for AHPs.

Commissioner Jones noted the need to ensure self-funded AHPs are actuarially sound.

Ms. Patterson said New Hampshire has reviewed its rules and found them to be inappropriate for the new fully insured AHPs. The state has convened a stakeholder group to look at the issue for legislation in 2019.

Director Cameron asked Committee members if their states are likely to submit new Section 1332 applications under the new rules.

Director Wing-Heier said the new rules will help the process, noting that the new Alaska governor may be interested in another waiver.

Mr. Wieske said Wisconsin, by state law, is developing a report on waiver options that is due by the end of the year.

Having no further business, the Health Insurance and Managed Care (B) Committee adjourned.

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Agenda Item #2

Consider Adoption of the Regulatory Framework (B) Task Force Report and Request for Model Law Development—Commissioner Michael Conway (CO)

2019 Spring National Meeting Orlando, Florida

REGULATORY FRAMEWORK (B) TASK FORCE Saturday, April 6, 2019 11:30 a.m. – 1:00 p.m.

Meeting Summary Report

The Regulatory Framework (B) Task Force met April 6, 2019. During this meeting, the Task Force:

1. Adopted its Feb. 26, 2019, and 2018 Fall National Meeting minutes, which included the following action: a. Discussed its 2019 proposed activities and its subgroup and working group 2019 proposed activities.

2. Adopted the report of the Pharmacy Benefit Manager Regulatory Issues (B) Subgroup report, which met March 22 and took the following action: a. Discussed and adopted a Request for NAIC Model Law Development to develop a new NAIC model establishing a registration or licensing process for pharmacy benefit managers (PBMs).

3. Adopted the Pharmacy Benefit Manager Regulatory Issues (B) Subgroup’s Request for NAIC Model Law Development.

4. Heard a presentation on Montana’s use of transparent pricing/contracting to address costs in the State of Montana Benefit Plan.

5. Heard presentations on the opioid epidemic and the potential role of state insurance regulators in fighting it.

6. Heard a presentation on the ClearHealth Quality Institute’s (CHQI) Mental Health Substance Use Disorder (MH/SUD) Parity Accreditation Program standards and its online parity tool.

7. Adopted the report of the Accident and Sickness Insurance Minimum Standards (B) Subgroup, which has not met since July 2018. As soon as the Subgroup finalizes a chair, it plans to begin meeting again sometime after the Spring National Meeting to continue its discussion of revisions to the Model Regulation to Implement the Accident and Sickness Insurance Minimum Standards Model Act (#171).

8. Adopted the report of the HMO Issues (B) Subgroup. The HMO Issues (B) Subgroup completed its initial work with the Regulatory Framework (B) Task Force’s adoption at the 2018 Fall National Meeting of its recommendation to open the Health Maintenance Organization Model Act (#430) for revision due to changes to the Life and Health Insurance Guaranty Association Model Act (#520). The Health Insurance and Managed Care (B) Committee adopted the recommendation during its Feb. 14 conference call. Virginia has volunteered to chair the Subgroup in 2019. It is anticipated the Subgroup will meet soon after the Spring National Meeting to first adopt a charge for 2019 and then begin work on revising Model #430.

9. Adopted the report of the ERISA (B) Working Group, which met April 6 and took the following action: a. Adopted its 2018 Fall National Meeting minutes. b. Discussed association health plans (AHPs), including the potential impact of the federal district court ruling in State of New York v. United States Department of Labor concerning the U.S. Department of Labor’s (DOL) final rule on AHPs. c. Adjourned into regulator-to-regulator session pursuant to paragraph 2 (pending investigations which may involve either the NAIC or any member in any capacity), paragraph 3 (specific companies, entities or individuals) and paragraph 8 (consideration of strategic planning issues) of the NAIC Policy Statement on Open Meetings.

W:\National Meetings\2019\Spring\Summaries\Final Summaries\RFTF.docx

2019 Spring National Meeting Orlando, Florida

ERISA (B) WORKING GROUP Saturday, April 6, 2019 10:30 – 11:30 a.m.

Meeting Summary Report

The ERISA (B) Working Group met April 6, 2019. During this meeting, the Working Group:

1. Adopted its 2018 Fall National Meeting minutes.

2. Discussed association health plans (AHPs), including the potential impact of the federal district court ruling in State of New York v. United States Department of Labor concerning the U.S. Department of Labor’s (DOL) final rule on AHPs.

3. Adjourned into regulator-to-regulator session pursuant to paragraph 2 (pending investigations which may involve either the NAIC or any member in any capacity), paragraph 3 (specific companies, entities or individuals) and paragraph 8 (consideration of strategic planning issues) of the NAIC Policy Statement on Open Meetings.

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This form is intended to gather information to support the development of a new model law or amendment to an existing model law. Prior to development of a new or amended model law, approval of the respective Parent Committee and the NAIC’s Executive Committee is required. The NAIC’s Executive Committee will consider whether the request fits the criteria for model law development. Please complete all questions and provide as much detail as necessary to help in this determination.

Please check whether this is: New Model Law or Amendment to Existing Model

1. Name of group to be responsible for drafting the model:

Pharmacy Benefit Manger Regulatory Issues (B) Subgroup of the Regulatory Framework (B) Task Force

2. NAIC staff support contact information:

Jolie Matthews [email protected]

3. Please provide a brief description of the proposed new model or the amendment(s) to the existing model. If you are proposing a new model, please also provide a proposed title. If an existing model law, please provide the title, attach a current version to this form and reference the section(s) proposed to be amended.

The Subgroup has a charge to consider developing a new NAIC model to establish a licensing or registration process for pharmacy benefit managers (PBMs).

4. Does the model law meet the Model Law Criteria? Yes or No (Check one)

(If answering no to any of these questions, please reevaluate charge and proceed accordingly to address issues).

a. Does the subject of the model law necessitate a national standard and require uniformity amongst all states? Yes or No (Check one)

If yes, please explain why

The proposed new model would provide a consistent approach among the states for providing a regulatory scheme for these entities to address, for some states, a potential regulatory gap.

b. Does Committee believe NAIC members should devote significant regulator and Association resources to educate, communicate and support this model law?

Yes or No (Check one)

5. What is the likelihood that your Committee will be able to draft and adopt the model law within one year from the date of Executive Committee approval?

1 2 3 4 5 (Check one)

High Likelihood Low Likelihood

Explanation, if necessary: The current subgroup would target completion of a model within one year.

6. What is the likelihood that a minimum two-thirds majority of NAIC members would ultimately vote to adopt the proposed model law?

1 2 3 4 5 (Check one)

High Likelihood Low Likelihood

Explanation, if necessary: Some states have already implemented laws and/or regulations establishing a regulatory scheme for these entities, which may or may not be consistent with the provisions in the proposed new model. For those states with laws or regulations not consistent with the new model’s provisions, the issue will be whether these states will want to re-open those laws or regulations after adoption the new model.

7. What is the likelihood that state legislatures will adopt the model law in a uniform manner within three years of adoption by the NAIC?

1 2 3 4 5 (Check one)

High Likelihood Low Likelihood

8. Is this model law referenced in the NAIC Accreditation Standards? If so, does the standard require the model law to be adopted in a substantially similar manner?

9. Is this model law in response to or impacted by federal laws or regulations? If yes, please explain.

No. However, the U.S. Department of Health and Human Services (HHS) has proposed rules on rebating safe harbors. In addition, the HHS and/or other federal government agencies currently are considering proposing further federal policy guidance in the areas concerning PBMs and prescription drug pricing transparency and disclosure. In developing the new NAIC model, the Subgroup most likely will be discussing the same or similar issues.

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Agenda Item #2A

Consider Adoption of its Subgroup, Working Group and Task Force Reports —Commissioner Jessica Altman (PA)

Conference Calls

CONSUMER INFORMATION (B) SUBGROUP March 29, 2019 / March 15, 2019 / February 11, 2019

Summary Report

The Consumer Information (B) Subgroup of the Health Insurance and Managed Care (B) Committee met via conference call March 29, March 15 and Feb. 11, 2019. During these calls, the Subgroup:

1. Developed a work plan for 2019. The Subgroup intends to create four documents during the year. The first will be a consumer alert consisting of questions consumers should ask when shopping for health coverage or when they receive a telemarketing call related to health coverage. The other documents will be consumer guides. They will provide information to help consumers: Shop for coverage, use their coverage, and get bills paid.

2. Began drafting the consumer alert. The Subgroup considered a first draft of the consumer alert and gathered suggested edits. It plans to continue refining the alert after the Spring National Meeting.

Draft: 4/3/19

Consumer Information (B) Subgroup Conference Call March 29, 2019

The Consumer Information (B) Subgroup of the Health Insurance and Managed Care (B) Committee met via conference call March 29, 2019. The following Subgroup members participated: Angela Nelson, Chair, Amy Hoyt, Carrie Couch and Mary Mealer (MO); William Rodgers (AL); Alexandria Peck (IN); Mary Kwei (MD); Andrew Kleinendorst (MN); Kathy Shortt (NC); Martin Swanson (NE); Cuc Nguyen, Lydia Shirley and Rebecca Ross (OK); Katie Dzurec (PA); Candy Holbrook, Gretchen Brodkorb and Mallori Barnett (SD); Jaakob Sundberg and Tanji Northrup (UT); and Eric Cormany, Susan Ezalarab, Barbara Belling, Rebecca Rebholz and Jennifer Stegall (WI). Also participating were: Jacob Lauten (AK); Dayle Axman (CO); Debra Pierce (GA); Nicholas Lee (HI); Sonya Sellmeyer and Cynthia Banks-Radke (IA); Michelle Baldock (IL); Emily DeLaGarza (MI); Bob Williams (MS); Vickie Trice (TN); Scott Helmcamp (TX); Yolanda Tennyson (VA); Anna Van Fleet (VT); Dena Wildman, Greg Elam, Joylynn Fix and Theresa Miller (WV); and Denise Burke (WY).

1. Discussed the Draft Question List

Ms. Nelson provided an overview of the Subgroup’s work plan as decided on the previous call. The Subgroup plans to develop four products: 1) a consumer alert titled, “What to Ask When Shopping for Health Coverage”; 2) a consumer guide on choosing a plan; 3) a consumer guide on using coverage; and 4) a consumer guide on how to get claims paid when there is an issue.

Ms. Nelson stated that the draft question list sent via email to the Subgroup was truly a rough draft, and participants should suggest any changes, big or small. She asked whether the overall structure of the document is what the group had in mind.

Harry Ting (Chester County Department of Aging Services, Apprise Program) said he especially likes the “Questions to ask yourself” and “Questions to ask about a plan you’re considering” sections. He suggested adding a glossary, noting that consumers want advice from someone on which plan to choose.

Ms. Nelson responded that the document should refer to the glossary on Healthcare.gov. She said she believes the document should not get into providing advice on which plan to choose, because that gets into the realm of licensed agents.

Mr. Swanson suggested several questions for the list: What is your license number?; Do I have to pay to join a group to get coverage?; What is the direct number to call you back?; and Can you send me this information in writing?

Ms. Nelson asked whether an introduction to the “Questions to ask if you receive a phone call about health insurance” section would be good. Mr. Swanson said it would be, and perhaps a warning that consumers may be contacted after they search online for health insurance options.

Ms. Mealer suggested adding that it is a red flag if a consumer must login to an account to get needed information.

Mr. Swanson asked whether there should be a section dedicated to shopping online.

Ms. Stegall mentioned that Wisconsin produced a consumer alert in 2018 that cautioned against providing personal information such as a Social Security numbers or bank information.

Ms. Dzurec said it is easy to get into the “weeds” on plan types, given that some short-term plans are sold through associations. She added that sometimes providing personal information is necessary, so the warning should be not to provide it until a consumer has verified the person or entity they are dealing with, and not simply to withhold personal information at all times.

Mr. Ting suggested adding that a consumer does not need to make a decision during a call.

The Subgroup also suggested not including information about tiers in formularies, and suggested consumers ask, “Will I be able to use my doctor?” rather than ask about access to a provider directory.

Ms. Nelson asked how fine-tuned the document should be; i.e., if it should be ready to use or customizable by states. Mr. Swanson said it could be both: a product ready for distribution, but one the states can feel free to adapt.

The Subgroup requested that any other comments and suggestions be submitted by April 8. Another conference call will be scheduled for the second half of April.

Having no further business, the Consumer Information (B) Subgroup adjourned.

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Draft: 3/26/19

Consumer Information (B) Subgroup Conference Call March 15, 2019

The Consumer Information (B) Subgroup of the Health Insurance and Managed Care (B) Committee met via conference call March 15, 2019. The following Subgroup members participated: Angela Nelson, Chair, and Mary Mealer (MO); Yada Horace (AL); Donna Daniel, Kathy McGill and Elaine Mellon (ID); Alexandria Peck, Claire Szpara, Karl Knable, and Jenifer Groth (IN); Mary Kwei (MD); Judith Watters (ME); Martin Swanson and Laura Arp (NE);[NT1] Cuc Nguyen and Rebecca Ross (OK); Alison Beam and Katie Dzurec (PA); Gretchen Brodkorb and Jill Kruger (SD); Jaakob Sundberg (UT); Melanie Anderson (WA); and Eric Cormany, Jody Ullman, Susan Ezalarab, Barbara Belling and Jennifer Stegall (WI). Also participating were: Jacob Lauten and Chelsy Maller (AK); Howard Liebers (DC); Andria Seip and Cynthia Banks-Radke (IA); Mike Chrysler (IL); Josh Rayborn (KY); Renee Campbell (MI); Bob Williams (MS); Pam Koenig (MT); Maureen Belanger (NH); Jana Jarrett (OH); Victor Woods (RI); Teresa Luna (TX); Yolanda Tennyson (VA); Dena Wildman and Theresa Miller (WV); and Denise Burke (WY).

1. Discussed its Work for 2019

Ms. Nelson recapped the Subgroup’s prior conference call. She mentioned that the Subgroup discussed posting materials developed in 2018 to the NAIC website and developing new materials this year. She explained that a smaller group had met separately to consider work products for the Subgroup.

Ms. Nelson reviewed the smaller group’s recommendations, which consisted of four products. The first product would be a consumer alert that would list questions for consumers to ask when shopping for coverage. It would help consumers navigate the information they get while shopping and ask for additional information they need.

Ms. Nelson described the other three products as a series of consumer guides. One would cover shopping for coverage and could borrow from the Health Insurance Shopping Tool the Subgroup developed in 2018. The next would cover how consumers can best use coverage, explaining cost-sharing and deductibles, networks, formularies, and how to seek care in the most appropriate and/or least expensive setting. The final guide would offer help in getting claims paid. It would describe how to read an explanation of benefits, consumers’ appeal rights and how to contact the state insurance department or other regulators to get help.

Ms. Nelson asked whether this plan sounded good to the Subgroup. Ms. Watters and Ms. Kruger expressed support for developing the materials as described.

Ms. Watters said two issues coming up in Maine are the differences between the different types of non-Affordable Care Act (ACA) coverage, as well as accessing catastrophic plans using the affordability exception. Ms. Dzurec agreed that a lot of things are becoming confusing, given the way producers bundle different products. She said state insurance regulators should stay on top of things, as marketing shifts every year.

Chris Petersen (Arbor Strategies) mentioned that the Accident and Sickness Insurance Minimum Standards (B) Subgroup is making changes to the Accident and Sickness Minimum Standards Model Act (#170). He said the Subgroup may want to wait and see what that Subgroup is doing.

Candy M. Gallaher (America’s Health Insurance Plans—AHIP) suggested making sure that consumers find the content of the guides actionable. Rather than questions to ask, she suggested a framing of “know what you are buying.” A list should encourage consumers to ask themselves what they are looking for and then provide considerations for each answer.

Katie Keith (Out2Enroll) said the NAIC consumer representatives had commissioned a consumer test of short-term plan documentation to better understand consumer comprehension of their terms. The results will be rolled out at the Spring National Meeting.

Ms. Stegall suggested that the consumer alert have two pieces: one for consumers going into open enrollment and another focused on how to respond to telemarketers.

Eric Ellsworth (Consumers Checkbook) pointed out that www.healthcare.gov has “From Coverage to Care” materials, noting that these might be useful for the guide about using insurance.

Joe Touschner (NAIC) suggested that there are many types of coverage, and the Subgroup should consider which ones the guides will be applicable to and how to convey that. Ms. Nelson said she was thinking they would apply only to major medical coverage. The Subgroup discussed how to treat other types of plans, including health care sharing ministries. Ms. Arp suggested including a phone number or website for information on other plan types and possibly a statement that health care sharing ministries are not insurance and, therefore, are not subject to state-based insurance regulation.

Ms. Nelson suggested working on the consumer alert first, followed by using coverage and getting bills paid, and finally back to the shopping tool in time for open enrollment.

Ms. Dzurec said it would be good to have a document to work from when considering the consumer alert. The Subgroup decided that participants would send suggested questions to Mr. Touschner, who would then circulate a draft to the Subgroup. The Subgroup decided that suggested questions would be due March 22 and its next conference call would occur March 29.

Having no further business, the Consumer Information (B) Subgroup adjourned.

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Draft: 3/1/19

Consumer Information (B) Subgroup Conference Call February 11, 2019

The Consumer Information (B) Subgroup of the Health Insurance and Managed Care (B) Committee met via conference call Feb. 11, 2019. The following Subgroup members participated: Angela Nelson, Chair, Jessica Schrimpf, Carrie Couch and Amy Hoyt (MO); Yada Horace (AL); Donna Daniel and Elaine Mellon (ID); Claire Szpara (IN); Tate Flott (KS); Mary Kwei (MD); Candace Gergen and Maybeth Moses (MN); Kathy Shortt and Rosemary Gillespie (NC); Laura Arp (NE); Cuc Nguyen (OK); Elizabeth Hart (PA); Gretchen Brodkorb and Candy Holbrook (SD); Heidi Clausen and Jaakob Sundberg (UT); Melanie Anderson (WA); and Christina Keeley, Darcy Paskey, Julie Walsh, Lisa Brandt, Mary Kay Rodriguez, Sue Ezalarab, Barbara Belling and Jennifer Stegall (WI). Also participating were: Jacob Lauten and Chelsey Maller (AK); Jackie Smith and Donna Lambert (AR); Gloria Barnes-Jackson (AZ); Julia Heath (CA); Laura McCandle (DE); Matthew Guy and Pam White (FL); Debra Peirce (GA); Mark Ono (HI); Andria Seip, Angela Burke Boston and Cynthia Banks-Radke (IA); Michelle Baldock (IL); Frank Opelka (LA); Emily DeLaGarza (MI); Josh Ammerman and Bob Williams (MS); Jeannie Keller, Ashley Perez and Pam Koenig (MT); Gary Weiss (NJ); Mark Garratt (NV); Tynesia Dorsey (OH); Brian Hoffmeister and Vickie Trice (TN); Scott Helmcamp (TX); Yolanda Tennyson (VA); Christina Rouleau (VT); Barbara Hudson and Dena Wildman (WV); and Denise Burke (WY).

1. Discussed its Work Plan for 2019

Ms. Nelson explained that she wanted to open the floor for suggestions on the Subgroup’s work plan, but said she first wanted to review the Subgroup’s charges.

Ms. Nelson reminded the Subgroup of its work to develop the Health Insurance Shopping Tool and asked whether any states had made use of it. Ms. Arp reported that Nebraska has used the shopping tool in presentations around the state, given it to consumer support staff and shared it with academic researchers. Ms. Nelson said the Missouri Department of Insurance had placed the tool on its website and promoted it on social media.

Ms. Nelson briefly discussed the Frequently Asked Questions About Health Care Reform (FAQ) document. Ms. Shortt asked how the FAQ document had been distributed. Joseph Touschner (NAIC) said it had been emailed to the contact list for the Subgroup and included in Brian R. Webb’s (NAIC) Health Reform Update email.

Ms. Nelson asked whether the FAQ document was available on the NAIC website. Mr. Touschner said working versions were posted, but not the final version. The Subgroup discussed whether the FAQ should be posted on its web page. Some noted that the FAQ document requires state-specific material that state insurance regulators must add before it is complete. Others observed that the 2015 version of the FAQ document is available on the web page, but not the 2018 update. Ms. Stegall suggested that it should be posted on the website, with disclaimer language to describe its intended use. Others agreed.

Eric Ellsworth (Consumers Checkbook) suggested that disclaimer language include a statement that the document does not apply to short-term health plans. Ms. Nelson and Mr. Touschner said individual questions already include information on whether they apply to short-term health plans.

The Subgroup next discussed whether the Health Insurance Shopping Tool should be posted on the NAIC website. Some said it should have greater functionality or be in a checklist format. Others said it just needs a more attractive layout, noting that the Subgroup should not wait for the perfect document but instead use what is available. Ms. Nelson suggested that the existing tool be submitted to the NAIC Communications Division to see if it can be developed into something more useful and engaging, perhaps a web page, app or video.

Ms. Nelson asked the Subgroup to think through its next steps now that open enrollment is over. She suggested providing answers for the basic things that trip up consumers when they are using insurance. She asked what information the Subgroup would like to communicate.

Ms. Mealer said the biggest issue is certification, then grievances and appeals. Ms. Shortt said a comparison chart would be helpful to allow consumers to understand the differences between qualified health plans (QHPs), association health plans (AHPs), short-term plans and health care sharing ministries.

Ms. Mealer said there are concerns with AHPs, noting that a one-page that describes what they are would be helpful. Chris Petersen (Arbor Strategies) pointed out that the updated Health and Welfare Plans Under the Employee Retirement Income Security Act: Guidelines for State and Federal Regulation (ERISA Handbook) has related information.

Ms. Arp noted that a document with questions to ask when a consumer gets a call offering cheap health insurance would be useful. Ms. Mealer suggested something geared toward young adults and something that describes how a bill goes through the claims process. Others suggested infographics, differences with student health insurance and appeals.

The group also discussed explanation of benefits (EOB) forms. Candy Gallaher (America’s Health Insurance Plans—AHIP) said it would be helpful to report state requirements for EOBs. She said real estate on the EOB form is scarce and there is a lot of mandated language.

Ms. Nelson outlined three general areas the group had suggested: 1) claims; 2) a comparison between different kinds of coverage; and 3) questions to ask when shopping. She asked for volunteers to flesh out these ideas and report back to the Subgroup. Ms. Anderson, Ms. Kwei and Ms. Mellon volunteered.

Having no further business, the Consumer Information (B) Subgroup adjourned.

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2019 Spring National Meeting Orlando, Florida

HEALTH ACTUARIAL (B) TASK FORCE Friday, April 5, 2019 3:00 – 5:00 p.m.

Meeting Summary Report

The Health Actuarial (B) Task Force met April 5, 2019. During this meeting, the Task Force:

1. Adopted the report of the Health Care Reform Actuarial (B) Working Group, which included the following action: a. Heard an update from the federal Center for Consumer Information and Insurance Oversight (CCIIO).

2. Adopted its March 5, 2019; Jan. 10, 2019; and Dec. 21, 2018, minutes, which included the following action: a. Adopted draft changes to the Medicare Supplement Insurance Model Regulation Compliance Manual (Manual) necessitated by the federal Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). b. Adopted a request for the American Academy of Actuaries (Academy) and Society of Actuaries (SOA) to update the 2005 Group Term Life Waiver Mortality and Recovery Table (2005 Table).

3. Adopted the report of the Long-Term Care Actuarial (B) Working Group, which included a summary of its April 5 meeting. During its April 5 meeting, the Working Group took the following action: a. Adopted its 2018 Fall National Meeting minutes. b. Adopted the report of the Long-Term Care Valuation (B) Subgroup. c. Adopted the report of the Long-Term Care Pricing (B) Subgroup.

5. Adopted the Long-Term Care Pricing (B) Subgroup’s Feb. 14, 2019; Jan. 24, 2019; Jan. 10, 2019; and Nov. 29, 2018, minutes, which included the following action: a. Discussed an all-state long-term care insurance (LTCI) rate increase review survey. b. Discussed company solvency considerations used in LTCI rate reviews. c. Discussed potential cross-state policyholder rate subsidization.

7. Heard an update from the Academy Council on Professionalism.

8. Heard an update from the SOA on health insurance research.

9. Heard an update from the SOA on work related to the 2005 Table.

10. Heard an update from the Academy Health Practice Council. w:\National Meetings\2019\Spring\Summaries\Final Summaries\HATF.docx

2019 Spring National Meeting Orlando, Florida

HEALTH INNOVATIONS (B) WORKING GROUP Saturday, April 6, 2019 3:30 – 5:00 p.m.

Meeting Summary Report

The Health Innovations (B) Working Group met April 6, 2019. During this meeting, the Working Group:

1. Heard a presentation on the National Governors Association’s (NGA) initiatives on health innovations, which included a discussion of NGA’s efforts related to the federal Affordable Care Act’s (ACA) Section 1332 waivers, value-based purchasing, prescription drug pricing, and surprise billing. 2. Discussed a reinsurance proposal from Colorado, with remarks from Commissioner Michael Conway (CO) and Mike Brown of Lewis & Ellis. Mr. Brown shared the results of actuarial modeling of Colorado’s original plan to re-price high claims based on Medicare rates. Commissioner Conway explained that re-pricing will be removed from the plan due to concerns about federal approval of the waiver, but he expects to move ahead with state funding coming from an assessment on hospitals. 3. Discussed the different state approaches to the ACA Section 1332 waivers. Working Group members with waivers approved or in development shared their experiences, challenges, and lessons for other states. 4. Reviewed the process for updating essential health benefits (EHBs), with Jennifer Reif of the Illinois Department of Insurance. Ms. Reif explained the steps the state took to meet the short timeline for submitting a request to update EHBs by the federal deadline. Group members discussed their states’ plans for submitting their own requests. 5. Discussed innovative initiatives from Working Group member states and future directions for the Working Group. The Working Group members discussed state individual mandates, Medicaid buy-in, state single payer, cost trend targets.

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2019 Spring National Meeting Orlando, Florida

LONG-TERM CARE ACTUARIAL (B) WORKING GROUP Friday, April 5, 2019 1:00 – 3:00 p.m.

Meeting Summary Report

The Long-Term Care Actuarial (B) Working Group met April 5, 2019. During this meeting, the Working Group:

1. Adopted its 2018 Fall National Meeting minutes, which included the following action: a. Adopted a draft resource document that explains and compares different long-term care insurance (LTCI) rate increase review methodologies. b. Adopted the report of the Long-Term Care Pricing (B) Subgroup. c. Adopted the report of the Long-Term Care Valuation (B) Subgroup.

2. Adopted the report of the Long-Term Care Pricing (B) Subgroup, which included the following action: a. Adopted the its Feb. 14, 2019; Jan. 24, 2019; Jan. 10, 2019; and Nov. 29, 2018, minutes, which included the following action: 1. Discussed an all-state LTCI rate increase review survey. 2. Discussed company solvency considerations used in LTCI rate reviews. 3. Discussed potential cross-state policyholder rate subsidization.

3. Adopted the report of the Long-Term Care Valuation (B) Subgroup.

4. Heard an update from the American Academy of Actuaries (Academy) on Long-Term Care Valuation Work Group activities.

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2019 Spring National Meeting Orlando, Florida

SENIOR ISSUES (B) TASK FORCE Saturday, April 6, 2019 2:15 p.m. – 3:30 p.m.

Meeting Summary Report

The Senior Issues (B) Task Force met April 6, 2019. During this meeting, the Task Force:

1. Heard a discussion about entities that are conducting genetic testing and DNA swabs in nursing homes, senior homes and other entities. The Task Force discussed reports of entities going into nursing homes, assisted living facilities and senior centers to “swab” individuals purportedly to look for genetic markers for cancer and further discussed that while genetic testing is allowed in certain circumstances by Medicare, it is unclear if those limitations are being followed by these entities. The Task Force also discussed how some individuals may be billed in the event that Medicare or the Advantage plan did not pay for the testing, and how the method of how consent to test is obtained and what is done with the genetic material after the test is completed is unclear.

2. Heard a discussion from the National Association of Health Underwriters (NAHU) about the how it is educating and informing its agents and brokers about the upcoming changes to Medigap Plan C and Plan F as a result of the changes mandated by the Medicare Access and CHIP Reauthorization Act (MACRA).

3. Heard an update on federal legislative matters. The update included a report on the status of the federal appropriations process as it relates to the funding for the State Health Insurance Program (SHIP).

4. Heard an update on the progress by states on the implementation of the changes mandated by MACRA. The update included the results of a survey of states that the NAIC conducted on where states are in their implementation process of the Medigap changes mandated by MACRA and two new alert bulletins aimed at consumers and producers to dispel the lies and myths about the upcoming MACRA changes.

5. Heard a discussion about Medicare and the Consolidated Omnibus Budget Reconciliation Act (COBRA) issues. The number of people working past age 65 today is the highest it has been in 55 years, and it is projected that 36% of people between the ages of 65 and 69 will be in the labor force by 2024. As a result, a significant number of people are likely to experience being eligible for COBRA and Medicare at the same time in the future, and more and more consumers are experiencing being billed for expenses that should have been billed to Medicare. The Task Force agreed to draft a letter to the U.S. Department of Labor and the Centers for Medicare and Medicaid Services (CMS) about this matter.

6. Adopted its March 7, 2019 and 2018 Fall National Meeting minutes, which included the following action:

a. Discussed its 2019 activities. b. Disbanded the Short Duration Long-Term Care Policies (B) Subgroup and the Long-Term Care Shopper’s Guide (B) Working Group.

W:\National Meetings\2019\Spring\Summaries\SITF.docx

Agenda Item #3

Hear a Panel Presentation on Health Care Cost Data—Kim Holland (Blue Cross and Blue Shield Association—BCBSA), Kevin Kennedy (Health Care Cost Institute—HCCI) and Maureen A. Mustard (NH) The Cost of Healthcare

NAIC Health & Managed Care (B) Committee April 6, 2018

Kim Holland Vice President, State Affairs

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 2

Agenda

WHAT DRIVES HEALTHCARE COST INCREASES POLICY OPTIONS TO COSTS CONTROL COSTS

19-206-W20 3

National Health Expenditures Healthcare expenditures are consuming greater portions of family and public budgets • The amount Americans spend on healthcare nationally is mind-boggling: a total of $3.5 trillion per year, or nearly 1 in 5 dollars in the entire U.S. economy (18.2% GDP)1 – This approaches nearly $1,000 each month for every person in the country. These costs exceed most households’ budgets for food, gas, housing or other common necessities.

• Spending is expected to grow 5.5% annually over the next decade to reach nearly $6.0 trillion by 20271 – Other high income countries spent only 9.6-12.4% of their GDP on healthcare, averaging less than half of what the U.S. pays2

1. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html 2. https://www.healthsystemtracker.org/chart-collection/how-do-healthcare-prices-and-use-in-the-u-s-compare-to-other-countries/#item-patients-in-the-u-s-have-much-shorter-average-hospital-stays-than-patients-in-comparable- countries_2018 19-206-W20 4

Private Insurance Per Capita Cost Growth has Outpaced Public Programs

Growth of Major Sources of Healthcare Financing, 1995-20151 Average Price per Inpatient Stay2 500 $25,000 450 400 $20,000 350 300 $15,000 250 200 $10,000 150 100 $5,000 50 0 $0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Private Health Insurance Medicare Medicaid

Note: All payers are indexed at 100 in 1995. In 1995, Medicare’s average age was 74.7 years. The average increased slightly over the period before settling back at 74.7 by 2015.

1. Per Capita Costs; Note: All payers are indexed at 100 in 1995. In 1995, Medicare’s average age was 74.7 years. The average increased slightly over the period before settling back at 74.7 by 2015. National Health Expenditure Accounts (CMS), we took what they had in 1995 and then monitored growth and note that private (employer and individual) health spending is growing much faster . 2. Thomas M. Selden analysis of AHRQ’s Medical Expenditure Panel Survey for the Kaiser Family Foundation. Update of earlier analysis, available here: https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2015.0706 19-206-W20 Source: National Health Expenditure Accounts (CMS), we took what they had in 1995 and then monitored growth and note that private (employer and individual) health spending is growing much faster . 5

Strain on Individuals and Families Consumers gauge the growing costs of healthcare through the expenses they pay

• Out-of-pocket expenditures have grown $19,407 or 102% of 30,000 steadily since 1970, averaging $1,124 a new Honda Civic per capita in 2017, up from per $18,940 $119 25,000 capita in 1970 ($601 in 2017 dollars)1 $15,635 $14,122 • About one-in-ten adults said that 20,000 they either delayed or did not receive medical care due to cost 15,000 2 in 2017 $13,375 or 86% of 10,000 $5,791 or 41% of a a new Honda Civic • 2018 premiums for an employer- new Honda Civic sponsored family health insurance policy 5,000 now costs $19,407, roughly the base 1999 2009 2018 3 sticker price of a 2018 Honda Civic Family Premium Honda Civic

1. https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/#item-health-spending-generally-grows-faster-than-general-economic-inflation_2017 2. https://www.healthsystemtracker.org/chart-collection/cost-affect-access-care/#item-most-adults-are-in-better-health-and-most-have-health-insurance_2017 3. Chart analysis completed using 2017 Employer Health Benefits Survey, Kaiser Family Foundation, 19 September 2017, available at: https://www.kff.org/health-costs/report/2017- employer-health-benefits-survey/ 19-206-W20 6

Commercial Costs by Type of Care Percentage of Total Paid Claims and Per Member Per Year (PMPY) costs by category, 2017

Prescription Drugs Inpatient $1,134 $1,236 21% 22%

Physicians and Other Professionals $1,290 23% $1,646 30% $201 2% Outpatient ER

Data provided by Blue Health Intelligence https://bluehealthintelligence.com/ 19-206-W20 7

What Are the Main Drivers of Cost Increases?

Prices for healthcare goods and services Chronic disease Rx Costs • Provider market power Behaviors such as poor diet, • Highly correlated with patent continues to grow as smoking, lack of exercise, protections hospitals merge and etc. can lead to costly purchase physician chronic health conditions practices • Physicians are also forming large groups

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Concentrated Provider Markets Have Led to Price Increases • Large, consolidated systems increase prices and premiums, without accompanying improvements in quality of care1 • There have been nearly 1,600 hospital mergers in the past 20 years, with over 450 since 2012. The result is that the majority of local areas are now dominated by one large, powerful health system.2 – Several recent papers find evidence that such mergers lead to significant hospital price increases between 20-30%, with some increases as high as 65%3 – Physician services markets have also become increasingly more concentrated. Two-thirds of specialist physician markets are highly concentrated, and 29% for primary care physicians.2

1. https://www.healthaffairs.org/do/10.1377/hblog20190320.450197/full/ 2. Martin Gaynor statement before the Committee on the Judiciary, Subcommittee on Antitrust, Commercial, and Administrative Law, U.S. House of Representatives. March 7, 2019 3. Taken from Gaynor’s testimony but studies cited are: Town and Vistnes, 2001; Krishnan, 2001; Vita and Sacher, 2001; Gaynor and Vogt, 2003; Capps et al., 2003; Capps and Dranove, 2004; Dafny, 2009; Haas-Wilson and Garmon, 2011; Tenn, 2011; Thompson, 2011; Gowrisankaran et al., 2015). 19-206-W20 9

Chronic Disease Many chronic conditions are costly and avoidable • Nearly 150 million Americans (60%) are living with at least one chronic condition; around 100 million of them have more than one. And nearly 30 million are living, with five chronic conditions or more.1 – Those with five or more conditions, represent about 18% of the U.S. adult population, but account for more than 50% of U.S. health spending.1 • The most prevalent chronic conditions among adults in 2015 were hypertension (26%), hyperlipidemia (20%), mental disorders and arthritis (17%) and diabetes (11%). – Among patients with heart disease, pulmonary disease, diabetes, hypertension and hyperlipidemia, approximately 75% were either overweight or obese.1

1. Understanding and Preventing Chronic Disease. Ken Thorpe, PhD February 2019. https://assets.aspeninstitute.org/content/uploads/2019/02/AHSG-Chronic-Disease-Report-2019.pdf?_ga=2.246914116.1732157684.1553716414- 1803104790.1553716414 2. https://www.rand.org/blog/rand-review/2017/07/chronic-conditions-in-america-price-and-prevalence.html 19-206-W20 10 Spend for Chronic Conditions – Commercially Insured PMPY costs for most conditions categories grow substantially with age 2017 Health Care Costs (V3 Health Index Data) Gen Z Millennial Gen X Baby Boomer Percent of Condition Category (0-20) (21-36) (37-52) (53-64) Total Cost Musculoskeletal $223 $326 $738 $1,345 13% Gastrointestinal $238 $453 $614 $785 10% Cancer $77 $123 $476 $1,159 9% Cardiovascular $64 $138 $468 $1,154 9% Endocrine (including Diabetes) $146 $158 $393 $723 7% Neurological $145 $211 $423 $513 6% Respiratory $300 $191 $272 $429 6% Behavioral health $331 $367 $256 $190 6% Maternal $20 $618 $111 $0 4% Skin $103 $141 $221 $274 4% 18-279-W20 Note: dollars and percentages rounded to nearest whole number. 11

Prescription Drug Spending and Chronic Disease Treating chronic diseases accounts for more than 86% of U.S. healthcare costs

• As of 2016, chronic disease accounted for over $2 trillion in healthcare spending per year and another $794 billion in lost productivity1 • Chronic diseases require long-term management and usually cannot be cured, which exacerbates the high cost to patients for medicines over a long period of time2 – 30% of Americans are not taking their prescriptions as directed, due to rising costs3

• Prescription drug spending, which reached $480 billion in 2016,4 is expected to be the fastest growing segment in healthcare, averaging 6.3% growth from 2017–20265 – Per capita spending for pharmaceuticals is $1,443 in the US, compared with a range of $466 to $939 in other nations6

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BCBSA Policy Proposals for Cost Control

Reduce the Prevalence Bring Down Drug Prices of Chronic Disease

Provide Relief From High Prices For Medical Care

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V-BID: Improving Care and Reducing Cost

Blue Cross and Blue Shield Plans are partnering with physicians to provide resources, data, and identify care gaps

Touches more than 300,000 patients Program involves 9 million Program impacts 1 million and involves almost 400 physicians members and 83,000 providers members and involves 10,000 providers • 38% improvement in diabetes care; • $1.25 billion cumulative savings 74% improvement in hypertension first three years of program • $14 pmpm savings and 15% fewer care; improvement in vascular 45% • decline in inpatient days ER visits for PCMH members disease care, improvement in 7.6% 70% and fewer readmissions • savings and higher kidney disease care 37% $8 pmpm 6% immunizations rates in children for • 4.26% decrease in total cost ACO members of care per member

18-279-W20 The Cost of Healthcare

NAIC Health & Managed Care (B) Committee April 6, 2018

Kim Holland Vice President, State Affairs

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. NAIC: Health Care Spending Trends for the Commerically Insured

Kevin Kennedy April 2019 Quick HCCI Background

Prior to HCCI’s formation: ▪ Access to payer data was piecemeal with researchers primarily relying on limited Medicare data for research and analysis ▪ There was little to no transparency in health care pricing/prices

HCCI was founded in 2011 to: ▪ Promote independent, nonpartisan research and analyses on the causes of the rise in U.S. health spending ▪ Inform the public policy process and assist in developing new solutions to long-term problems confronting the health care system

HCCI facilitates informed debate about health care reform by generating insights from commercial and public payer data HCCI Governance

Independent Board • Bob Town, UT-Austin, Chair • Mike Chernew, Harvard • Leemore Dafny, Harvard • Dale Yamamoto, Independent Actuary • Aneesh Chopra, Entrepreneur, former White House CTO • Chuck Phelps, University of Rochester (retired) • Almeta Cooper, Morehouse University (retired) • Aaron McKethan, Duke/NC HHS • Stephanie Carlton, McKinsey • Amy Finkelstein, MIT • Marshall Votta, Nautic Partners HCCI Data Holdings

Commercial Claims Medicare Fee-For-Service Claims ▪ Years: 2008-2017 ▪ Years: 2012-2016 ▪ All 50 states and D.C. ▪ National Qualified Entity (QE) ▪ Updated annually ▪ Updated semi-annually ▪ 25% of ESI population ▪ 100% Parts A & B & D ▪ De-identified, HIPAA and anti-trust ▪ Identified compliant

Individual ESI MA FFS Medicare 4.5M 42.9M 6.1M 40.5M HCCI ESI Data Coverage - 2017

Percent of state ESI population

ME CA 30% 19% VT NH MT ND 5% 15% 7% 9% MN NY OR 19% MA WI 20% 14% ID SD 14% 31% MI 12% 6% WY 10% PA NJ CT RI 12% IA 32% 27% OH 22% 35% NE 19% IL IN NV 29% 30% DE 25% 19% WV MD 21% UT VA 26% CO 13% 26% 25% KY 26% CA 35% KS MO 28% DC 30% 32% NC 20% 34% TN 21% 25% OK AR SC AZ NM 24% 17% 16% 42% 16% MS AL GA 22% 9% 31% TX LA 43% 27% FL 39% AK 40%

HI 2% 2017 Health Care Cost and Utilization Report

A review of trends in health care spending, utilization, and price among Americans with employer- sponsored insurance If you only remember 3 things from today….

Health care spending is continuing to grow

Rising prices are driving growth overall

Variation across service categories and sub-groups provide insight into areas to focus reform efforts Executive Summary

In 2017, per-person spending reached a new all-time high of $5,641. This total includes amounts paid for medical and pharmacy claims (including discounts but excluding rebates).

Spending per-person grew at a rate above 4% for the second year in a row, rising 4.2% from 2016 to 2017 - slower than the 2015 to 2016 rate of 4.9%.

The overall use of health care changed very little over the 2013 to 2017 period, declining 0.2%. In 2017, utilization grew 0.5% compared to 2016.

Prices increased 3.6% in 2017. Year-over-year price growth decelerated throughout the five-year period, rising 4.8% between 2013 and 2014 and slowing to 3.6% in 2016 and 2017.

Out-of-pocket spending per-person increased 2.6% in 2017. The growth was slower than the rise in total spending, so out-of-pocket costs comprised a smaller share of spending by 2017. Per-person spending reached new all-time high

Spending per Person in 2017 Annual Spending per-person Total $5,641

Professional Inpatient Services $1,097 $1,898 19.5% 33.6%

Prescription Outpatient Drugs $1,580 $1,065 28.0% 18.9%

Note: Prescription drug spending is amount paid on pharmacy claim, which reflects discounts from wholesale price, but not manufacturer rebates paid in separate transactions. Increasing prices drive health care spending growth

Cumulative Change in Spending per-person, Utilization, and Average Price since 2013

Average Price

Spending Utilization

Note: Except for prescription drugs, utilization reflects volume and service-mix intensity. Thus, the prices presented factor out changes in the mix of services used for these three categories. Additionally, prescription drug spending is the amount paid on the pharmacy claim, which reflects discounts from the wholesale price, but not manufacturer rebates paid in separate transactions. Use and price trends vary across service categories

Annual Percent Change in Spending per-person, Utilization, and Average Price Total Inpatient Outpatient

Professional Services Prescription Drugs

Spending Utilization Average Price

Note: Except for prescription drugs, utilization reflects volume and service-mix intensity. Thus, the prices presented factor out changes in the mix of services used for these three categories. Additionally, prescription drug spending is the amount paid on the pharmacy claim, which reflects discounts from the wholesale price, but not manufacturer rebates paid in separate transactions. Spending levels and growth vary by population sub-groups

2017 Spending per person by Age 2017 Spending per person by Number of Chronic Conditions

Growth since 2013 Out-of-pocket spending increased steadily, but slower than total spending

Cumulative Change in Out-of-Pocket and Total Spending per member since 2013 Share of Spending Paid Out of Pocket

Total Spending

OOP Spending Annual spending growth varied by service & subservice

Annual Percent Change in Spending per Person, 2016-2017

• There‘s more to it than just the average

4.2% • Within each service category, variation existed in spending grwoth rates across subservice categories, too Inpatient Admissions – Service Subcategories

Annual Percent Change in Spending per Person, 2016-2017 Cumulative Change in Spending, Utilization, and Average Price, 2013-2017 Mental Health/ Substance Abuse: +11%

4.2%

Labor/Delivery/ Newborns: +2% Outpatient Facility Visits – Service Subcategories

Annual Percent Change in Spending per Person, 2016-2017 Cumulative Change in Spending, Observation: +13% Utilization, and Average Price, 2013-2017

4.2%

Lab/Pathology: +2% Professional Services – Service Subcategories

Annual Percent Change in Spending per Person, 2016-2017 Cumulative Change in Spending, Utilization, and Average Price, 2013-2017 Administration of Drugs: +12%

4.2%

Anesthesia: +2% Prescription Drugs – Service Subcategories

Annual Percent Change in Spending per Person, 2016-2017 Cumulative Change in Spending, Rheumatoid Arthritis Utilization, and Average Price, 2013-2017 Drugs: +23%

4.2%

Cardiovascular Drugs : -17% Other Resources: State Level Interactive Tool

https://healthcostinstitute.org/research/hccur/ 2017-health-care-cost-and-utilization-report Other Resources: Healthy Marketplace Index

https://www.healthcostinstitute.org/ research/hmi/hmi-interactive#HMI- Price-and-Use Other Resources: Health Affairs 10-Year ESI Retrospective

https://www.healthaffairs.org/doi/ full/10.1377/hlthaff.2018.0481 Final Thought

People are spending more because prices are rising, but what are those higher costs buying us? Q & A

Questions?

Find the report and resources at: healthcostinstitute.org/research/annual-reports

Contact or follow us [email protected] @HealthCostInst New Hampshire Insurance Department

Healthcare Claims Data and Price Transparency in New Hampshire Establishment of Claims Database

• 2003 NH passed RSA 420-G:11-a requiring the development of a Comprehensive Health Care Information System – Chapter Ins 4000: Uniform Reporting System for Health Care Claims Data Sets • 2005 – NH began collecting claims data • Healthcare claims database is often referred to as All-Payer Claims Database • 14 other states are actively collecting claims data and 5 more are implementing newly enacted laws.

4/3/2019 Page 2 NH’s Unique Approach

• New Hampshire is unique in using insurance authority to collect claims data • Ins 4005.03 Opt-In by Self-Funded Private Employers – adopted following the Supreme Court decision in Gobeille v. Liberty Mutual • Database protects privacy – All claims are de-identified • Hashing system creates unique person keys to identify a person during data submission process

4/3/2019 Page 3 What is Included in the Database

• NHCHIS includes medical, dental and pharmacy claims • Eligibility files provide information on the members and plans • NHCHIS contains nearly 14 billion claims incurred by members over 14 years • Paid, reversed and denied claims are all included

4/3/2019 Page 4 How NHID Uses Claims Data

• A statewide rate report, produced quarterly, shows charge and paid amounts for thousands of procedures

• An innovative network adequacy rule adopted in 2018 supports increased transparency and market competition

• New Hampshire recently passed a law prohibiting balance billing and will rely on the claims data to help determine the reasonable market rate for payment

• Claims data are often used to determine the potential implications of mandate and market reform efforts – These analyses help to inform lawmakers of the potential impact of a particular piece of legislation on cost.

4/3/2019 Page 5 NHHealthCost.org

• NH HealthCost website was created by NHID in 2007 to improve the price transparency of healthcare services – included approximately 35 cost estimates

• Site re-launched in 2016 with over 100 cost estimates, hospital quality data and a guide to health insurance and improved user experience

4/3/2019 Page 6 Health Cost Estimates

• Methodology developed to show accurate outpatient cost estimates that is easy to understand • Bundled estimates are calculated for procedures that involve multiple providers and services are based on date of service • Unbundled estimates are calculated simply at CPT code level for transactional services • Partially bundled estimates include costs for facility and provider and are used for radiology procedures without regard for other costs that might occur on the same day

4/3/2019 Page 7 Impact of Transparency in NH

Early indications of transparency impact • Heightened awareness of price variation – Price shopping tools with incentives • Benefit design innovation resulted from focus on wide variation in provider prices – Site of service/tiered copayment products • Changes in plan-provider leverage

4/3/2019 https://www.nh.gov/insurance/reports/documents/moving-markets.pdf Page 8 New Research on Transparency

• “HealthCost website reduced the cost of medical imaging procedures by 5 percent for patients and 4 percent for insurers. A simple calculation implies that individuals saved around $7.9 million and insurers saved $36.0 million on X-Ray, CT scan, and MRI scans over the 5 year period.” – A 2018 Study by an economics professor at the University of Michigan • Researchers at Harvard University are studying the impact of a Google AdWords campaign that is driving NH specific web traffic to certain procedures on NHHealthCost – Funded by the Donoghue Foundation

4/3/2019 Page 9 Increased Traffic

• NHID promoted use of site through influencers in NH communities • Improved search engine optimization • Harvard-Google partnership

4/3/2019 Page 10 Nationwide Interest

2018 NH HeatlhCost usage from each state 4/3/2019 Page 11

Thank You

Contact Information

New Hampshire Insurance Department 21 South Fruit Street, Suite #14 Concord, NH 03301 [email protected] Phone: (603) 271-2261 Fax: (603) 271-1406 TTY/TDD: 1 (800) 735-2964

www.nh.gov/insurance

[email protected]

4/3/2019 www.nhhealthcost.org Page 12

Agenda Item #4

Hear an Update on Legal Action Surrounding the Federal Affordable Care Act (ACA) —William G. Schiffbauer (Law Office of William G. Schiffbauer, Chartered) UPDATE ON THE STATUS OF FEDERAL AFFORDABLE CARE ACT LITIGATION

NAIC Spring National Meeting Health Insurance and Managed Care (B) Committee Orlando, Florida April 7, 2019

By William G. Schiffbauer, Esq. Major Pending Litigation

I. Texas et al v. United States of America et al, pending in the U.S. District Court, Northern District of Texas

II. State of New York et al v. United States Department of Labor et al, pending in the U.S. District Court, District of Columbia

III. Association for Community Affiliated Plans et al v. United States Department of the Treasury et al, pending in the U.S. District Court, District of Columbia

2 THE INDIVIDUAL MANDATE I. Texas et al v. United States of America et al

3 I. Texas v. US

TIMELINE December 22, 2017, Tax Cut and Jobs Act of 2017 is signed into law.

February 26, 2018, complaint filed by 20 Republican-led states.

April 9, 2018, petition filed to intervene as Defendants by 17 Democrat-led states-DC.

4 I. Texas v. US

TIMELINE September 5, 2018, oral argument held. Federal Defendant requested delay of decision due to “open enrollment” (November 6, Election Day).

November 16, 2018, Maine withdraws as a party plaintiff.

December 14, 2018, District Court rules for the plaintiffs and issues order and opinion for partial summary judgment.

5 I. Texas v. US

TIMELINE December 28, 2018, Wisconsin withdraws as a party plaintiff.

January 3, 2019, U.S. House of Representatives files intervention to join as Defendant.

January 7, 2019, Defendants file appeal and become Appellants. Case is docketed at Fifth Circuit Court of Appeals.

6 I. Texas v. US

TIMELINE February 5, 2019, Hawaii withdraws as party plaintiff.

March 25, 2019, briefs filed by Appellant States and U.S. House of Representatives Intervenor.

March 25, U.S. DOJ files notice that the Federal Appellant now agrees with the U.S. District Court and become “Appellee”.

7 I. Texas v. US

TIMELINE April 1, 2019, twenty Amicus Curiae briefs filed for Appellants by advocates, health care providers, insurers opposing District Court’s opinion.

April 1, 2019, Amicus Curiae brief filed by Ohio and Montana for Appellants but arguing for limited severability not entire ACA.

April 24, 2019, Appellee States and Federal “Appellee” must file reply briefs.

8 I. Texas v. US

TIMELINE Fifth Circuit oral arguments not yet scheduled. Could be scheduled for June or July.

Fifth Circuit will issue order and decision after oral arguments. Could be August or September.

Parties will file Petition for Certiorari to SCOTUS. Could be October – for 2019 Term.

9 I. Texas v. US

PLAINTIFF’S ARGUMENTS

Tax Cut and Jobs Act of 2017 eliminated ACA individual mandate tax penalty.

Stand-alone mandate without tax penalty is not supported by the Commerce Clause.

10 I. Texas v. US

PLAINTIFF’S ARGUMENTS

Community-rating, guaranteed-issue provisions are inseverable from mandate.

Injunction must apply to the rest of the ACA “major provisions”.

11 I. Texas v. US

FEDERAL DEFENDANTS’ REPLY

The Individual Mandate is Unconstitutional After the Tax Cut and Jobs Act.

The Mandate is Not Severable from the Guaranteed Issue and Community Rating Provisions.

The Mandate, Guaranteed-Issue, and Community Rating Provisions are Severable from ACA.

12 I. Texas v. US

FEDERAL DEFENDANTS’ REPLY

Preliminary Injunctive Relief is Not Warranted but a Declaratory Judgment would be appropriate.

Request a holding that the individual mandate will be unconstitutional as of January 1, 2019.

13 I. Texas v. US

STATE-INTERVENOR DEFENDANTS’ REPLY

Individual mandate penalty remains and production of revenue is not a constitutional requirement.

The penalty can be characterized as a tax with a delayed effective date or suspension.

Penalty payments will continue to raise revenue because liability for 2018 is not due until April 2019.

14 I. Texas v. US

STATE-INTERVENOR DEFENDANTS’ REPLY

The Tax Cut and Jobs Act amendment to reduce the penalty to $0 is unconstitutional.

If the Individual Mandate as amended is found to be unconstitutional it is severable from the entire ACA.

15 I. Texas v. US

ORAL ARGUMENT HIGHLIGHTS

The District Court appeared to agree with the Plaintiff’s arguments that the mandate is now unconstitutional.

The District Court was primarily concerned with the scope of severability and application to all or only the Plaintiff states.

16 I. Texas v. US

ORAL ARGUMENT HIGHLIGHTS

Court noted the 111th Congress in 2010 characterized the mandate as integral to guaranteed-issue and community rating.

Court noted the 115th Congress in 2017 only repealed the amount of the penalty and left the remainder of the ACA in place.

17 I. Texas v. US

DISTRICT COURT’S OPINION

Individual mandate may no longer be upheld under the Tax Power of the Congress or the Commerce Clause.

Relies upon CJ Roberts NFIB v. Sebelius that the penalty no longer produces revenue in present tense.

Congress did not just suspend or delay the penalty, it eliminated the individual mandate penalty.

18 I. Texas v. US

DISTRICT COURT’S OPINION

Individual mandate is “essential” to the ACA and cannot be severed from the ACA’s remaining provisions.

Relies upon joint dissent severability rationale of four conservative Justices in NFIB v. Sebelius.

Cites six statutory references in ACA text and “findings” stating individual mandate is “essential” to the Act.

19 I. Texas v. US

DISTRICT COURT’S OPINION

Court’s attempt to “sever” interdependent provisions would “rewrite” the statute violating Separation of Powers.

The 2017 amendment did not mean that Congress wanted the ACA to survive without the mandate.

The 2017 amendment did not remove the requirement to purchase insurance or the “findings” that the mandate is “essential” to the Act.

20 I. Texas v. US

FIFTH CIRCUIT COURT OF APPEALS

Maintains a reputation as the most politically conservative circuit court of appeals.

Five of the Fifth Circuit’s seventeen judges have been appointed by President Trump.

Eleven of the seventeen active judges were appointed by a Republican President.

21 I. Texas v. US

FIFTH CIRCUIT COURT OF APPEALS State Defendants-Appellants argue that: 1. State-Plaintiff Appellees do not have standing – District Court did not address fiscal injury. 2. The Coverage Provision is a “condition” or choice with no legal obligation that remains Constitutional . 3. If Unconstitutional the Coverage Mandate is severable from the rest of the ACA.

22 I. Texas v. US

FIFTH CIRCUIT COURT OF APPEALS U.S. House Defendants-Appellants argue that: 1. NFIB v. Sebelius held that the ACA offered a choice between buying insurance or paying a tax. 2. State-Plaintiff Appellees and Individual Appellees do not have standing. 3. If Unconstitutional the Coverage Mandate is severable from the rest of the ACA.

23 ASSOCIATION HEALTH PLANS II. State of New York et al v. United States Department of Labor et al

24 II. New York v. US DOL

TIMELINE June 21, 2018, U.S. Department of Labor publishes final rule for Association Health Plans.

July 26, 2018, complaint filed by State of New York and 11 other states (10 Democrat-led).

January 24, 2019, oral arguments held on New York motion for summary judgment.

25 II. New York v. US DOL

TIMELINE March 28, 2019, District Court issues order and opinion granting New York motion.

April 2, 2019, DOL posts FAQ on District Court’s ruling and impact on AHPs.

Federal Defendants have not yet filed an appeal with the D.C. Circuit Court of Appeals.

26 II. New York v. US DOL

PLAINTIFF’S ARGUMENTS

Final rule unlawfully overrides the Affordable Care Act’s employer-group market structure with the association health plans.

Final rule unlawfully expands the ERISA definition of “employer” to include a “working owner”.

Final rule is an arbitrary and capricious departure from long-standing interpretations of “bona fide association”.

27 II. New York v. US DOL

FEDERAL DEFENDANTS’ REPLY

ERISA statutory term “employer” includes a group or association of employers acting in relation to an employee benefit plan.

AHP final rule is a reasonable interpretation of ERISA term “employer” because it is ambiguous and “group or association” is undefined.

28 II. New York v. US DOL

FEDERAL DEFENDANT S’ REPLY

Federal agencies may permissibly modify long- held sub-regulatory guidance and not foreclosed by other statutory provisions.

Statutory definition of “employer” is silent with respect to number of “employees” and final rule is a “reasonable” interpretation.

29 II. New York v. US DOL

DISTRICT COURT’S OPINION

The Final Rule is clearly an end-run around the ACA to avoid the most stringent requirements of the Act.

The Final Rule does violence to ERISA’s careful statutory scheme that is based on employment relationships.

The Final Rule extends ERISA to cover commercial insurance transactions between unrelated parties.

30 II. New York v. US DOL

DISTRICT COURT’S OPINION

The AHP is an entrepreneurial venture selling insurance outside of ERISA’s “employment relationship” scope.

The Final Rule has no meaningful limit on associations having a commonality of interest or control to be ERISA “employers”.

31 II. New York v. US DOL

DISTRICT COURT’S OPINION

The inclusion of “working owners” in contrary to the text of ERISA that requires an “employment relationship”.

ERISA defines an “employee” to be an individual employed by an employer and so anticipates two parties.

32 II. New York v. US DOL

DISTRICT COURT’S OPINION

The bona fide association and working owner provisions are unlawful and vacated.

The Final Rule includes a “severability” clause and remands the rule to DOL for consideration.

Not vacated are the subsections captioned “(a) In general”, “(d) Nondiscrimination”, “(f) Applicability dates”.

33 SHORT-TERM LIMITED DURATION INSURANCE III. Association for Community Affiliated Plans et al v. United States Department of the Treasury et al

34 III. ACAP v. US TREASURY

TIMELINE August 3, 2018, ACA Tri-Agencies publish final rule for Short-Term, Limited-Duration Health Insurance.

September 14, 2018, complaint filed by Association for Community Affiliated Plans and 6 other organizations.

October 26, oral argument hearing held on request for preliminary injunction.

35 III. ACAP v. US TREASURY

TIMELINE November 12, 2018, Plaintiffs withdraw request for preliminary injunction.

March 15, 2019, Parties file briefs on motion for summary judgment.

March 22, 2019, Parties file replies to arguments on summary judgment.

36 III. ACAP v. US TREASURY

TIMELINE April 2, 2019, the Court accepts and files amicus briefs submitted supporting plaintiff.

District Court could issue and order and ruling in May or June.

The Parties are expected to appeal to the D.C. Circuit Court of Appeals – a 1 year process.

37 III. ACAP v. US TREASURY

PLAINTIFF’S ARGUMENT

Final rule exceeded agencies authority and discretion and circumvents the purposes of the Affordable Care Act.

Final rule interprets “limited duration” to unreasonably encompass a renewal for up to three years.

38 III. ACAP v. US TREASURY

PLAINTIFF’S ARGUMENT “Short-term” should be based on the 3 month “short coverage gap” exemption from the mandate penalty.

Final rule does not provide a reasoned explanation for changing prior law and arbitrary and capricious.

Standing is satisfied based on injury from increased competition resulting from the Final Rule.

39 III. ACAP v. US TREASURY

FEDERAL DEFENDANTS’ REPLY

Congress did not define “short-term, limited- duration insurance” and delegated authority to the agencies.

Both HIPAA and the ACA maintained this authority for the agencies to issue regulations defining STLDI.

40 III. ACAP v. US TREASURY

FEDERAL DEFENDANTS’ REPLY

A “short coverage gap” is an exemption from the penalty tax along with hardship and financial constraints.

The final rule’s provision to permit renewal of 36 months restricts duration and so is “limited”. Prior ACA rule permitted unlimited extensions.

Plaintiffs have not established standing by demonstrating injury-in-fact.

41 III. ACAP v. US TREASURY

ORAL ARGUMENT HIGHLIGHTS

The Court expressed support for the Defendant-Tri- Agencies position and that STLDI offered a choice.

The Court suggested that the Plaintiffs drop the request for a preliminary injunction and proceed to merits.

The Court rejected the Plaintiffs “11th hour” request for an expedited ruling prior to November 1.

42 III. ACAP v. US TREASURY

ORAL ARGUMENT HIGHLIGHTS The Court observed that the case is about the insurance industry that markets the ACA being protected.

The Court observed that more insurance options was a net benefit and would help young people get coverage.

The Court suggested that STLDI plans should “play out” in the market and see if it really impacts ACA insurers.

43 THE END

Agenda Item #5

Hear Results of Consumer Testing Related to a Short-Term, Limited-Duration Plan (STLDP) —Katie Keith (Out2Enroll) and Susan Kleimann (Kleimann Communication Group) Consumer Understanding of Short-Term Plans

Susan Kleimann, PhD, Kleimann Communication Group www.Kleimann.com  What we did in St. Louis  Our research questions Overview  Our findings  Our conclusions  Other information . Recruited ten participants, 5 with chronic health conditions and 5 with no health condition. . Nine showed up and had varied demographics for education, age, insurance status, race, ethnicity, and other factors. . One-on-one interview . Interview Structure What we did in . Think-aloud . Quick overview on their own St. Louis. . Deeper reading of parts they wanted to read . Structured questions to test comprehension of content . Analysis . Comparative notes after interview . Review of transcripts for themes

3 What we found in St. Louis for 1. Can consumers understand the basic concept of a short-term health plan? five research 2. Can consumers identify basic coverage and non-coverage of the questions plan? 3. Do consumers read and use the federally mandated disclosure on the first page of the brochure? 4. Can consumers understand and apply the terminology and information in the health plan option charts? 5. Can consumers understand the trade-off of affordability versus coverage? Can  Simple answer: No consumers  Only two participants understood the concept from the start.  Others thought it was supplemental or extra insurance for understand anticipated expenses, such as maternity or surgery or dental work, the basic like braces.  Some understood better over time because of the interview; some concept of a never understood.  Even after an hour interview, some had the odd perception of the short-term plan being best-suited for people with high-risk jobs, old people who health plan? could afford the cost, or people getting ready to die. Can  Simple answer: No  Participants assumed what would be covered based on what they consumers expected current health plans to cover—pregnancy, pre-existing conditions, prescriptions. One mentioned Obamacare. identify basic  Participants who did eventually understand that pre-existing conditions were not covered still were unsure what constituted a coverage and pre-existing condition.  Some participants were concerned that if they did develop a serious non-coverage illness that the company would look for evidence to not cover them. For example, a mention of HBP in their medical record or an of the plan? immediate family member with cancer. Do consumers read and use the federally mandated disclosure on the first page of the brochure? Do consumers read and use the federally  Simple answer: No  Few participants even looked at the disclosure. mandated  The design of the page puts the emphasis on the photo and the table of contents and de-emphasizes the disclosure. disclosure on  Many thought the information was important and should be given prominence because it served as a guide for the important the first page information they should read. of the brochure? Can consumers understand and apply the terminology and information in the health plan option charts?  Simple answer: No  Participants turned to this page first because the information was Can consumers important, but they struggled because of layout and terminology.  Many found the layout confusing because the columns for the 4 options understand and were inconsistent, with a row sometimes running across the columns. apply the  Most participants did not understand “coinsurance,” confused by the percentage they would pay, thinking it was the same as copayment, or terminology and that it was like a cosigner of a loan.  Other terms were also confusing, such as “no balance billing” and even information in “lifetime” in the context of the chart.  Some did understand “deductible” but only because of a real world the health plan similarity with auto insurance’s deductible. option charts?  Consequence: Participants were unable to calculate simple estimates of their possible costs based on scenarios we gave them. Can  Simple answer: Yes and No consumers . Many participants understood that this insurance was relatively low cost and eventually, even if vaguely, understood the plan had understand limited coverage. . Many would have preferred a plan with more extensive coverage, the trade-off but cost was a factor. . Only two participants said they were willing to pay more per month of affordability in order to have substantially better coverage. . Yet, one participant wanted to get even less coverage and even versus lower costs. coverage?  Simple answer: ACA  Participants have been shaped by their experiences and expectations since the passage of the Affordable Care Act.  They expect pre-existing conditions to be covered.  They expect basic coverage for pregnancy, prescriptions, mental WHY? health.  So they read with a pre-existing anchor and psychological frame and expect the same things to be in this plan that they have seen in ACA plans. They do not read for differences.  No simple answers  Current marketing materials do not sufficiently help consumers break their expectations for content. The materials fail to emphasize their differences with ACA plans.  Consumers have a lack of health literacy that compounds their inability to calculate possible basic costs for a plan they might Our consider.  Poorly designed, poorly worded, badly formatted, and badly placed Conclusions disclosures rarely, if ever, are effective.  Disclosures in plain language, having visual prominence, using effective design, and being in a dominant position can be noticed, read, understood, and effectively shape the reading of subsequent information. Susan Kleimann, Ph.D. Kleimannn Communication Group Thank you. www.Kleimann.com 301.233.284

Agenda Item #6

Hear a Federal Legislative Update—Joseph Touschner (NAIC)

Agenda Item #7

Discuss the Federal Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and Next Steps for Future Discussions of the MHPAEA—Commissioner Jessica Altman (PA)

Agenda Item #8

Discuss Any Other Matters Brought Before the Committee —Commissioner Jessica Altman (PA)