 I will call to order the Green Mountain Care Board's hearing of February 7th. We have one agenda item relating to the QHP plans, and we'll have a vote hopefully on that. But first, we'll turn to the executive director for the executive director's report. Thank you, Mr. Chair. A few scheduling announcements. First, I wanted to let the remind the board and let the public know that on Monday, February 12th, we have a general advisory meeting, and that's via Teams. Then please check our website for our February schedule with our regularly scheduled board meetings. I also want to remind the ongoing public comment periods we have. We continue to accept any public comments on Act 167, Hospital Sustainability Work, and any of the comments related to the community engagement work we recently did, and any comments in general related to that work on Act 167. And then in addition, we have the ongoing public comment period for a next potential all payer model. We share any of those comments with Agency of Human Service and the administration as they are meeting and pushing each other's comments as well. And that, I will turn back to Mr. Chair. Thank you. And we have board minutes from Wednesday, January 31st. Is there a motion to approve the minutes? So moved. Second. All those in favor of approval of the minutes, please say aye. Aye. Aye. Aye. Sorry, we're having a hard time hearing you. I can probably guess what you're going to say, which is you're going to abstain because you did not participate in that hearing. So we will note that Dr. Merman is abstaining from voting and four members have approved the minutes. So the minutes are approved and we'll move to the 2025 standard qualified health plan design proposal and a potential vote. I'll turn to Mr. Hulahan in the event. Do you have any additional information for the board? Thanks for inviting us back today. We are here in follow up to our presentation of the proposed plan designs for 2025. I'm Dana Hulahan from the Department of Vermont Health Access and I'm joined by Darren Johnson and Julie Pepper of Wakely Consulting, our actuaries helping us through this process. So in follow up to last week's meeting, we had a request from the board to insert the 2024 premium amounts with each of the seven plan designs for as a point of reference and also to provide more information on the drivers of costs. And so in doing that, we'll Wakely has prepared some information and we'll also review some of the factors changing for 2025, which were fairly significant that impact the actuarial value calculator and other rules of the road for 2025. So Darren, if you're prepared, I'll go ahead and turn that to you. Thank you. Perfect. Thanks Dana. Yeah, so just a couple slides kind of reviewing some of the stuff we discussed last week and then we'll provide some more context for the premium impacts. Last week we kind of went through all these changes and then went through all the plan designs and in some ways I think it's nice to go through the plan designs and then after we've done that say, okay, this is how those changes kind of impacted impacted the designs that we looked at. So as a reminder, the two kind of big things that changed from 24 to 25 is that one, the maximum out of pocket limit decreased from 9450 to 9200. So there were several plan designs that had maximum out of pockets above that limit and those have to be reduced to 9200, which is a benefit increase. And that's the first time that's ever happened that that limit has gone down from one year to the following year. And then the other big change was the ABC updates. They changed the source of the data from 2018 mostly group data to 2021 EDGE data. The combination of that with some other methodological changes meant that silver and bronze, ABC, AVs especially were reduced. Whereas again, typically year over year we would see AVs only increase as the underlying data for the AV calculator is updated by HHS. So that was a big difference than what we usually see in the past and change kind of the landscape of what we were dealing with compared to prior years. And then as always our typical node on premium impact when we're looking at the both as a stakeholder group and then in this presentation when we're looking at premium impact, it helps to have trading off one plan design versus another. It helps to have some sort of estimate of what the premium impact of these different results are. So we use our own Wakely pricing AV calculator to assign an actuarial value to these plans to compare to the previous year's plan designs to give us kind of that data point. And then a change this year is that instead of just showing a percentage premium impact, we include it a estimated dollar premium impact using the 2024 premiums. So I'll just hop to a slide to show that. So for example on the platinum plan in the past we had just showed our preferred option as a 0.2% impact or backup option as a 0.4% impact. This year we took the 2024 premiums which we have added to the slide kind of for your feedback and then we can take that 0.2% and say okay that's a $30 impact annually. This one's a $56 impact annually and kind of added that data point. As always we caveat that premium impact pretty heavily. This is run on our model. It's national data. We try to calibrate it to Vermont experience but the issue where specific models will certainly be different, certainly be much more calibrated to Vermont experience and will likely have different results. And then the other kind of point of note there is that the 24 plan design is kind of our baseline for premium impact. We run on 24 projected costs and then when we're running our 25 plan designs we're running on kind of projected 25 costs based on typical Vermont trend. And I'll have a spreadsheet I'll pull up in a second to illustrate that a little more. But these premium impacts are not fully due to our plan design changes even if this year there is certainly more on that side than typical because of kind of those AVC and MOOP out-of-pocket max change factors that I mentioned. But a lot of it is due to the benefit leveraging where if costs increase the value of a given deductible or out-of-pocket max level increases as well. You know this silver plan has a 2.2 percent premium impact which is high and certainly higher than we typically see. Part of that component is that this plan has significant benefit increases over the previous years with copays being cut and the deductible and out-of-pocket max on the medical side decreasing. Another part of that is we're just assuming if costs increase at typical levels for Vermont the value of this plan design increases due to that. So that was the piece we wanted to add. As a note as you're going through these slides the other kind of work with this year is because the out-of-pocket limit decreased $250 any plan design that did not have a commissure decreased was flagged as green and requiring formal approval. So even you know this platinum plan where this backup option we don't touch the out-of-pocket max at all that requires explicit approval formal approval this year because of the the federal one decreasing by so much. So even a plan like this where we actually on the silver deductible decreased our out-of-pocket max a little bit we're not decreasing it $250 so it gets flagged as green. So I included all those slides just to have the premiums there to be able to look at probably the one other interesting point as you look through the issuer premiums is that they sometimes you know flip-flop on some of the the bronze plans and you know the HTHPs as which one thinks which plan is richer than another plan just to kind of illustrate the point that their own internal models are going to differ from the way that we model just due to having different data and being more Vermont specific. On the cost point we compile just a few a few little tables so this top table is our estimated premium impacts over the last three years we've been doing this which helps kind of illustrate that this year is atypical so in 2023 the typical premium impact was around 0.6 percent 24 was around 1 percent this year it's one and a half percent so the one takeaway is that that's going up due to the ABC changes we left plan designs the same or increased benefits whereas in a typical year we have to decrease benefits just to remain in compliance. The other key point is that that's not you know to the point I think raised last week this isn't a huge component of the overall rate increase that typically occurs. You know the second table we have you know the last few years what have trends look like so 2022 to 2023 the average trend was about 11 percent with most of that on the unit cost side in 23 to 24 trends dropped average projected trend this is from the urrt public files from the last last year's filings was about 7 percent so you know our portion of what we're adjusting with these plan designs you know can be meaningful 1.6 is you know an additional percent over 0.6 but it's only a piece of the of the whole puzzle and then the other note was just pulling the average individual market rate increases the last few years you know obviously these are you know there's a lot more going into this than just the premium impact and even just trend though trend is going to be obviously a big component of it there can be financial considerations regulatory changes and other factors that go into those beyond what we're kind of controlling here with these standard plan designs but just wanted to kind of include those as well as a little bit of extra extra information on on kind of drivers of cost go to my PDF um so yeah then the overall summary of what we've changed um again we reviewed all this last week um but this is kind of the the summary of the changes from from last year to this year Dana did that that cover it anything else that I missed yes I think so I think I'm just want to underscore the point when you say that benefits are increasing that means cost share decreases I think that's probably goes with it goes without saying but um that's what would drive premium up is by making a benefit richer so it's um decreasing cost share increasing the benefit as as um Darren was saying yeah in the case of like the silver plan we are decreasing the out-of-pocket max which is increasing the benefit which is decreasing cost share which will increase premiums all right yeah that's clear as mud a lot of a lot of this is to say as Darren pointed out that this is an unusual year where we're in that position with actually decreasing cost share with the ability to to decrease cost share in some of the plans um as a way of bringing the AV to a level that we as a stakeholder group got great about so again it's just unusual and as always we're trying to by doing these measured strategic changes our hope is to avoid uh big swings and changes required next year because this transition of the data and other factors are not expected to be a significant next year although we never know until we're given the rules yeah last year was also kind of a strange model with some methodological tweaks they gave us some room on some plans and I didn't expect it to continue this year and obviously it did so you never know but I would expect next year to be a much more standard standard update of the AVC model if you don't have anything else I'll open up to board member questions unless there's something else you want to share I think that's all we have for in terms of presentation great thank you um I appreciate you guys giving the additional information um that the board had asked for are there any other questions from the board members or comments anything from well actually I'll go ahead and make a motion and then I'll ask the help I think Tom was trying to so let's go ahead Tom so thanks I was muted um thanks for the additional information um a question on the premiums that you showed the boxes with those um that's per month right sorry yes that is that is a per member per month premium for an individual contract so right at individual level only the one pager that I distributed last week would contain I mean it's I know tiny print but it has individual couple adult and child and family tears as well so but what's in this box is just the individual level premium as the point of reference thank you Dana and I think it's really useful information just for all of us on the board to keep in mind um how expensive these are right on the low end $750 times 12 you know we're closing in on $9,000 just in premium right for the bronze and um somewhere north of 15,000 I think for the platinum and the the silver somewhere in between those but with very large deductibles right so it's somewhere around $10,000 to get in to the game to then be able to pay the deductible um so these are big numbers and I think it helps this the added information helps me keep that in mind um and the excel spreadsheet that you showed Darren um if I'm following that correctly the unit cost is another way for us to be able to think about that is the price increase right what providers are charging and their and the utilization are the two things that can drive up what insurers or payers have to reimburse on and quick math here 8.8 divided by 11 percent it looks like 80 percent of the change is driven by rising prices in 22 to 23 five divided by seven somewhere in the order of 70 percent um of the change in 23 to 24 driven by rising prices so utilization is a small matter in Vermont where we have an access problem and a healthy population rising prices are what is driving the rising premiums if I'm interpreting this data correctly yeah and I would I think that's definitely generally correct I do want to add my actuarial caveats um please I only pulled two years of data because the market was unmerged in 22 so I felt like including data before that you know was was not necessarily as representative which also means I'm including you know two years of trend in high inflation years with high rate increases that are not necessarily you know fully representative of the Vermont market but it felt like the best context to give um and then on the premium impact side the one you know one thing we're hoping and increasing benefits um knowing that that results in a higher premium impact is that hopefully subsidies will increase you know correspondingly obviously I think somebody raised the point last year those subsidies are still funded by tax dollars including Vermont tax dollars but that was kind of part of our part of our thinking as well great thanks thanks so much the other thing that to be honest was a surprise to me when I became a board member subsidies are useful for helping with premiums if I understand correctly they don't help with deductibles or co-pays yeah we do have on that side of it if you are under we keep this in the appendix um if you are under 250 of the fbl you do get the silver CSR plans that do have lower deductible so that's where there is you know some measure of assistance but yeah over that 250 fbl level it is only only premium yeah in Vermont actually in Vermont it's up to 300 sorry okay Richard yeah thanks thanks so much for the added information in the added context I really appreciate you um and at this point in time on the individual market we have over 90 percent of the people enrolled in the individual market receive some level of subsidy thank you can I just ask a quick follow-up question to that uh Darren when you look at the data that you pulled on the uh excel spreadsheet that you had up is there any way one thing that I hear is a driver of high insurance costs in Vermont is that we have a an older sicker population of people who are getting uh insurance on the commercial markets um I guess just wondering if if if looking at all the various states that you look at if that's something you can derive from the information that you see and and two when you look at this average individual market allowed claim trends where would that show up would that show up in the cost or the utilization if we were concentrate if the market was concentrating into a sicker population so it'll be a bit of both um and that you know an older population will use more and as they age more probably continue to use more um and use a higher cost mixed of services but I should say it's it's more going to be the base allowed level and the trend is going to be more cost increases um so like this unit cost trend your population is your population um and that's going to more reflect the prices being charged for the same services rather than the the aging of the population I would say from what I've seen um Vermont does seem to be higher cost um than a lot of states I kind of know Julie's Julie's popping in here who has even more experience with the Vermont market um but that that does impact some of the the AVs we calculate on sort of the pricing side and Julie I'll let you let you hop in here yeah I can I can I'll speak a little bit to the first question which um you know I think Vermont I think generally people always say that Vermont premiums are higher than other states but I think a lot of that has to do with the fact that it's community rated so it's not age rated so it appears higher um so a few years ago I think it's out there somewhere I could find if needed we did it we quickly did an analysis for the state of Vermont I think it might have been as part of the analysis on the unmerging of the markets but looking at Vermont premiums compared to other states and when you you know Vermont is does have a slightly higher age than the national average and so when you actually account for that and the premiums Vermont premiums are actually um lower I think than the average when you put it kind of an apples to apples basis so that was one thing I wanted to kind of just point out is that I think um people get have the perception that Vermont premiums are higher but they actually I think when we did the analysis we're actually a little bit slightly lower um than the other states that we looked at um when you normalize for age and just the the fact that it's community rated um and then to Darren's point you know even if you have a healthier older population you know the older you go obviously you get use more services and so you are more likely to hit your deductible and your maximum of pocket and use services more so again the federal AB calculator is you know set to a standard population but when it comes to pricing that could drive things a little bit um be to be a little more impactful and you would see in a federal AB calculator this is data this makes me think of another question is for um Darren and Julie is the unit cost 8.8 percent and 5 percent based on the population up to age 64 since that coincides with qhp or does it all of the population data be qhp okay that's why that's what I thought so it doesn't include the oldest cohort yeah this is directly from the urt's from that the issuers filed for the aca individual icing got it thank you yeah yeah and the one last thing is you know this this isn't separated for medical versus drug and you know both on the medical and drug side there have been a lot of new like uh you know Darren mentioned inflation so that's one big thing but there's also been a lot of new technologies and new drugs that are driving some costs higher as well so um you know so there there's been some some things lately that have definitely driven unit costs higher than what we've seen sometimes historically do you have national comparisons on unit cost not off the top of our head but we could pull it in send out once we do and then the other thing with the comparison between Vermont and other states I believe there's what something like 10 or 10 or 15 or 12 or 13 or something other states that have community rating are there um relevant comparisons between Vermont and those states i think it's just you in massachusetts i recall that you can or or what is this new york still the community there's only a couple i think i'm okay that might do um we could we could do a check um on that but let me know if the others think of others but i'm not aware of others outside of massachusetts and maybe new york any other board member questions or comments um i move excuse me to approve the 2025 qualified health plan designs as presented by the department of vermont health access including the proposed out-of-pocket maximum amounts i'll second any board member discussion on the motion any comment or question from the health care advocate as darin mentioned uh it was a very strange year and a lot of rather difficult decisions to make um our office uh fully supports um adopting this i think just the point of this is i suppose slightly different and i just wanted to clarify i mean the amount of production to deductible sharing that you get through the csr program right it varies by income level so you know the 250 to 300 range you depending on who you talk to i mean from my view it's a negligible reduction um to cost sharing obviously i think it's still wonderful that we have a state program but it is worth thinking about it also assume you have to assume to get csr you have to buy a silver plan so in addition to varying you could have some people who could qualify for a higher av value plan but then make the wrong decision and actually say they could get a gold plan av value if they purchase a silver plan but they buy a gold plan themselves so they don't get the csr but they're paying more premium um so looking at the distribution of csr eligibility versus the choices of plan would make sense it's something the board hasn't really looked at in the past to my knowledge um and then lastly turning to you know premiums i think this would be a somewhat more advantageous idea than silver loading would is to not allow um non-standard plans on the marketplace and so that would push up uh ppc because the benchmark would be higher it would also have the advantage which silver loading doesn't have um that it reduces consumer confusion um about health care options i think it's similar to what california does i do want to acknowledge that um you know small group small group market and members aren't eligible for ppc so you'd have to balance the benefit to individuals versus the harm um to the small group market i think you know within that um evaluation you would want to think about who is the most vulnerable um you would also want to take into consideration the fact that we did unmerge the market so that benefit to small group in reduced premiums might need to be taken account of um that's all i have thank you so much thank you um is there any public comment and if so please use the raise your hand function i will note for the record a a clap from mr carpenter walter do you have a comment a clap first and then um backing up tom and what eric said and tom pretty much said what i was going to say that overall when i look at the plans the premiums the deductibles the cost sharing and all the rest of it i think of the absolute cruelty of our market-based system and its utter failure because there's not a single vermont that can afford a nine thousand dollar deductible unless they're making hundred thousands of dollars a year most of us labor for 20 bucks an hour 25 bucks an hour and as someone who just got kicked off who joined who has just joined the 30 000 or so vermonters who has been kicked off of medicaid my costs now have gone up over four thousand dollars a year and if i lived in a country like denmark or norway or taiwan whatever pick one none of this would have happened so as much as we try to address these plans up there are other failures thank you walter for your comment and it's good to see you um any other public comment i miss you all and i miss you too it's nice to see you yeah i'm here i'm not hiding anywhere uh any other public comment okay great all those in favor of the motion please say i hi hi hi um the motion is approved unanimously and thank you um mr johnson and mr hula hand for your work with us the last couple weeks on this thank you all very much great thank you thank you have a good have a good day thank you so um that's the only substantive agenda item is there any older new business for the board today and a motion to adjourn so move second all in favor please say i hi hi hi and we are adjourned thank you have a good day