Displaying Clear Choice Plans

Launching an SBM offers the opportunity to adopt best practices for differential display of insurance plan options according to individual consumers’ health care and financial needs. Maine officials could use this opportunity to leverage the forthcoming standardized plan designs, called Clear Choice designs, with plan display decisions that advance the State’s broader mission of delivering SBM consumers a simpler shopping experience. This is particularly important from a health equity perspective because Clear Choice design plans can facilitate access to more comprehensive coverage for those historically marginalized by the health care system. This section explores the plan display, comparison, and decision tool interfaces used by SBMs and how the State of Maine could adapt these for its own SBM. Some approaches are specific to standardized plans, but most are applicable to all plans.

As Maine officials consider their approach to the SBM shopping interface, we make the following four

recommendations:

1. Use an intake questionnaire and show plans based on responses. 2. Build a comparison tool that: (1) automatically highlights differences between selected plans, and (2) includes a “Compare to Similar Plans” function. 3. Include a pop-up glossary feature when customers hover over a technical term, and enable screen reading audio capability for accessibility. 4. Distinguish Clear Choice plans with naming, visual cues, sorting, and/or filtering. Background

Standardized plans empower consumers by demystifying technical vocabulary and complex cost-sharing structures that, at best, create administrative burdens for the savviest consumers and, at worst, intimidate potential consumers to the point where they abandon applications and end up uninsured. Instead, standardized plans allow consumers to focus their comparisons on the basis of premiums, provider networks, and formularies to identify plans that best meet their needs. Seven states and Washington, DC require that some or all of the plans offered by marketplace carriers follow standardized plan designs.113 The federal marketplace also offered standard plan options for plan years 2017 and 2018.114

In Maine, Clear Choice designs will apply to plans with effective dates of January 1, 2022 and after. Plans adhering to the same Clear Choice design will share the same “set of annual copayments, coinsurance and deductibles for all or a designated subset of the essential health benefits.”115

Current draft guidance from the Bureau of Insurance clarifies some of the requirements for Clear Choice designs on the SBM but does not address how to display the plans.116 Publicly available Clear Choice Workgroup comments show that carriers and businesses believe standard plans increase costs because the benefits are more comprehensive, but these comments do not include stakeholder views on plan display.117 Our conversations with stakeholders therefore sought to clarify opportunities for displaying Clear Choice plans in a manner that is understandable to consumers.

Recommendation 1: Use an intake questionnaire to show consumers plans that fit their needs.

Several states with SBMs use some type of questionnaire to collect basic information that can be used to tailor the selection of plans displayed or the order in which they are shown based on their fit with a consumer’s needs. These tools are anonymous and separate from the application process; data entered in them is not saved.

These tools can take different forms. Colorado’s SBM guides consumers through a questionnaire covering household members’ ages, genders, tobacco use, level of health care usage, providers, and prescription drugs before they can view plan listings, although many questions are optional.118 Washington’s SBM asks for some of this information before showing plans, with an additional, optional “Smart Planfinder” tool that asks about providers, prescription drugs, and health care usage level.119

Once this information is collected, it can be incorporated into the interface in various ways: • Automatically sorting plans by estimated annual cost, as is done by SBMs in California, Colorado, and other states; • Allowing filtering for plans covering the providers and prescription drugs input by the consumer, similar to Healthcare.gov or the Colorado SBM; • Adding a visual cue to plans determined to be likely to fit the consumer’s needs, like Washington Healthplanfinder’s Smart Choice marker (see Figure 3); and/or

• Displaying the coverage status of the providers and These tools can also have a positive effect on affordprescription drugs input by the consumer with each ability by helping consumers make a cost comparison plan listing, as is done on Healthcare.gov and Washington Healthplanfinder (see Figure 3).i that incorporates estimated out-of-pocket expenses as well as premiums. Research on consumers’ MediWhichever approach is chosen, the same tools should care Part D choices found that beneficiaries placed be available for anonymous “window shopping,” useful more weight on premiums than out-of-pocket costs for consumers who want to compare options without and spent an average of $300 more than the cost of the submitting personal information that will be stored, lowest-cost plan covering their prescription drugs.122 and accessible for consumers who have created an ac- Studies have consistently found that the order in which count. options are presented impacts choices.123 Sorting plans Consumer Impact by estimated total annual cost could drive consumers toward plans with lower total cost, even if premiums A questionnaire and tools to check coverage of pro- are higher. viders and prescription drugs can limit the plans that consumers have to consider, significantly reducing the Utilizing an intake questionnaire would also have a complexity of the shopping experience. This in turn re- positive health equity impact. The burden of the marduces the “choice overload” that is endemic to health ketplace shopping experience is largest for marginalinsurance shopping, increasing the likelihood that con- ized populations, with limited time, higher stress and sumers will follow through with their enrollment.120 cognitive load, and on average lower levels of literaThere is a chance that filtering or sorting based on cy with health insurance terminology.124 Reducing the broad usage levels and other limited criteria may in complexity of the shopping process helps ease the some cases hide or deprioritize plans that a consumer burden on these consumers. However, the health equiwould prefer, leading them not to purchase any plan.121 ty impact of improvements to the SBM’s web interface However, the impact of reducing choice overload is is limited, as many populations, including immigrants, significant enough that the impact on coverage is ex- migrant workers, and rural residents work with compected to be positive overall. munity-based organizations and navigators or use the call center to choose and enroll in an insurance plan. Figure 3. Plan listing with Smart Choice marker and provider and prescription coverage indicators, Washington Healthplanfinder125

i Ideally, the coverage tier and copay would also be shown for each listed prescription drug and provider. Washington Healthplanfinder displays the formulary tier for each prescription drug that is selected, and each plan listing includes the copay for generic drugs, but copay information for other tiers is not shown. CLEAR CHOICE PLANS | 31

State Feasibility

Designing and implementing an intake questionnaire for SBM consumers is generally feasible. In our interviews, both carriers and consumer advocacy groups voiced support for these types of tools. Development of the questions themselves, particularly the health care usage levels used for estimating total annual cost, should be done in consultation with stakeholders and consumers to ensure that the options are representative of real usage patterns and that ease of use and understanding are high. Costs for this feature are not likely to be a hindrance, as the RFP specifically requires tools for provider and formulary lookup and for estimating total annual cost.126 Accurate and up-to-date information on provider networks and formularies will be necessary for these tools to be successful. Recommendation 2: Build a comparison tool that: (1) automatically highlights differences between selected plans, and (2) includes a “Compare to Other Standard Plans” function.

Comparison tools are an important marketplace feature and present an opportunity to leverage the simplicity and comparability of standardized plans. The FFM and SBMs that we reviewed allow comparison across three user-selected plans, with core plan features listed at the top, followed by many expandable categories to refine the side-by-side analysis (see Figure 4 below). The detailed information in these categories, while crucial, can have diminishing returns, as decision support tools are less useful when they include too many categories of comparison.127

Figure 4. Comparison Tool in Covered California128

Highlighting plan differences within the comparison tool would address this issue, by focusing consumer attention to the most relevant points. Similarly, allowing consumers an option to navigate to a pre-filled comparison of similar Clear Choice designs after selecting one such plan for more details would mimic common practices from e-commerce sites.ii Our review of the eight SBMs with standard plans did not find another marketplace that offered either of these features. Consumer advocates and one carrier that we spoke with suggested that these features would place the Maine SBM among the best marketplaces in terms of helping consumers understand how plans differ in formulary, provider networks, and total expected cost.

Consumer Impact

Our suggestions will simplify the shopping experience. Both features would reduce the number of clicks consumers using the online SBM would need to identify plan differences. These simplifications also might make it more likely that consumers complete the enrollment process. They also facilitate finding appropriate coverage. When consumers can easily identify plan differences, they are better able to select the right plan for their health needs and financial situation. This is particularly important to improve health equity. Reducing complexity in the insurance purchasing process would help all consumers, but especially historically marginalized groups who are less likely to be insured.129

State Feasibility

Maine’s RFP for an SBM technology platform vendor already calls for “clearly displaying standard features of plans, and emphasizing points of comparison.”130 This language allows for the technical features we suggest. In addition, stakeholders did not offer any indication that they would oppose this. Most were enthusiastic about the options that clarify the insurance enrollment process, including improving plan comparison tools. Recommendation 3: Include a pop-up glossary feature when customers hover over a technical term, and enable screen reading audio capability for accessibility.

Several of our stakeholder conversations revealed that the accessibility of the SBM to all groups in Maine is a critical health equity issue. One suggestion from the meetings was to improve visual cues that explain technical insurance vocabulary. Several SBMs include a popup glossary feature. The most common appearance is a question mark next to the term of interest (see Figure 5).

Figure 5. Pop-up glossary on the DC HealthLink comparison tool131

Including this feature on Maine’s SBM will help consumers decide among Clear Choice design plans by explaining which plan aspects are the same and which are different.

Consumer Impact

This display will improve health equity. Our conversations with patient advocates revealed that the specialized vocabulary of health insurance is a barrier to enrollment even when customers are eligible for significant subsidies. While several SBMs have collapsible pop-up glossaries for this jargon, we did not encounter any that offered an audio reader capability. Oregon and Vermont offer a potential model of a similar feature. Both states have plan comparison tools using the Consumer Checkbook platform, which offers an icon for brief explanatory videos next to technical terms. An

ii Since each Clear Choice design can be offered by every carrier, with up to three variations with different network types (HMO, PPO, and POS), this automatic comparison could either be between plans of the same design, with the same carrier, with different network types, or plans of the same design and network type across carriers. CLEAR CHOICE PLANS | 33

audio feature would be particularly useful for customers who are visually impaired. Including multi-language capability for this tool would be an important improvement for health equity as well.iii The feature will also reduce complexity. Including explanatory language helps make the shopping process simpler, regardless of whether a consumer opts for a Clear Choice plan.

State Feasibility

The RFP for the technology platform vendor includes “plan comparison and consumer decision support tools.”132 We believe that a pop-up glossary is a useful and important consumer decision support tool that falls under this category. Since other SBMs have similar features, the vendor may be familiar with this function. In addition, stakeholders did not offer any indication that they would oppose this. Most were enthusiastic about options that clarify the insurance enrollment process, such as clear definitions, visual elements, and high-quality translation. Advocacy groups we spoke with further recommended making it easy for consumers shopping on the SBM to contact someone by phone with questions by prominently displaying contact information and engaging with trusted community organizations to provide this assistance. Recommendation 4: Distinguish Clear Choice plans with naming, visual cues, sorting, and/or filtering.

For consumers to make informed decisions based on the characteristics that set Clear Choice plans apart from non-standardized plans, or to select Clear Choice plans for an apples-to-apples comparison, they must be able to identify Clear Choice plans. This can be accomplished in multiple ways, separately or in combination. First, some states with standardized plans include the plan’s standardization status in the plan title. Naming conventions include “ST” in New York; “Standard” in Connecticut, Massachusetts, and Oregon; and “Cascade” in Washington, where standardized plans and public option plans have together been branded as Cascade Care.133 A limitation of this approach is that consumers may not pay much attention to the plan name or be aware of its meaning.134 Another option is to use a visual element such as a badge or flag to mark standardized plans. DC HealthLink is the only SBM that does this (see Figure 6).135 In other SBMs, similar elements are used for other purposes: Massachusetts uses a “Network Alert” flag to mark plans with narrow networks, and Washington places a “Smart Choice” badge on plans that are suggested based on users’ reported health care usage. In both cases, hovering over the flag or badge brings up an explanation of its meaning.136 An element like this could both signify that a plan has a Clear Choice design and communicate to consumers what that designation means.

Thirdly, Clear Choice plans could be distinguished through the default sorting in the plan listings, so that they are shown first, with non-standardized plans below. This is not something other states currently do, but Massachusetts used to take a similar approach in

Figure 6. Standard Plan ribbon icon and filter on DC HealthLink’s Plan Match tool137

iii We suggest offering this tool in the most 5 common primary languages for non-native English speakers. U.S. Census data shows 6.1% of Mainers speak English as a second language, and 1.5% of Mainers report speaking English at a less than fluent level. See: https://data.census.gov/cedsci/table?g=0400000US23&tid=ACSDP5Y2019.DP02 34 | CLEAR CHOICE PLANS

Lastly, an option to filter for Clear Choice plans could be added, like the “Standard Plan” filter in DC HealthLink’s Plan Match tool (see Figure 6).138 This would allow consumers to more directly identify plans that share the same design across network types or carriers, so that these can be compared.iv,139 Even with a relatively limited number of plans on the SBM, determining which plans are meant to be comparable may not be intuitive to consumers.

Consumer Impact

All of these options would serve to reduce the complexity of the SBM for consumers. By helping consumers identify high-value plans with low cost-sharing, they could also improve overall affordability and improve coverage. However, because the premiums for Clear Choice plans are likely to be higher than those for non-standardized plans, there is some risk that consumers who are seeking a lower-cost plan may opt out of purchasing insurance if the lower-cost options are too difficult to find, neutralizing the potential positive impact on coverage.140 Distinguishing standardized plans to encourage consumers to consider them could have a positive impact on health equity in Maine by reducing the burden of the shopping experience, which is disproportionately high for marginalized populations because of time constraints and cognitive load.141 However, the health equity impact would again be limited as many Mainers opt to use the call center or work with an assister rather than using the SBM web interface.

State Feasibility

The feasibility of these options is generally high. Stakeholders expressed support for clearly differentiating Clear Choice plans, and while these features may add slightly to the complexity of developing the SBM technology platform, ongoing costs from updating or maintaining these features would be minimal. Ultimately, the feasibility of these features depends on whether the vendor contract is flexible enough to incorporate them without significant revision or added cost.

iv Carriers can offer a PPO, HMO, and POS version of each Clear Choice design.