 I'm the original member of the board, lost her spouse last night in a very public battle, and we've got lots of errors are with Karen. So it's my understanding that there is no executive direct issue for it. I have nothing to report tonight, thank you. Okay, so the first item on the agenda are the minutes of Wednesday, February 5th. So, it's been moved in seconded to approve the minutes of Wednesday, February 5th, on the additions, additions, and corrections to serve the discussion. Seeing none, all those in favor, signify by saying aye, in the close. I'd love to record now there's one exception. So with that, we'll invite the QHP design team down from. So I will go ahead and kick things off. This is Addie Strumlow, Deputy Commissioner at the Department of Vermont Health Access. I'm just gonna make a few brief remarks and then turn it over to my colleague Dana. Is the sound okay? Yes. Great. Least is here, so we'll get back there. And do we need to do anything to test that our colleagues from Wakely are available? Have we? If they wanna speak, we can make sure we can hear them, because it's on right now. Yeah, Julian, Brittany, are you on? Because it's Brittany, I'm on. You may have it on. Great, sounds good. Great, the gang is here. Thanks, so we're very happy to be here to present the proposals for the Standard Qualified Health Plan Designs for 2021. Just a few comments. One is that similar to last year, it was a bit of a time crunch. As you know, we're dependent on federal guidance. That guidance was posted on the 31st of January and published on February 6th, less a few days ago, essentially. So just wanted to give that context. There's now a 30-day comment period on the proposals and it's likely to be finalized in April. So that's just context for the recommendations that we're making today. We're always dependent on that information from CMS, which is not in a final form. The other comment I wanted to make is that I know it's helpful for the board to consider these recommendations with the context of the enrollment in the plans. We are just finalizing the enrollment numbers for 2020 and we'll have those hopefully ahead of next week's meeting for you all to see. And then third thought is you'll see in here that we are not having to implement changes unlike past years in response to legislation. However, you'll recall several years ago, there was legislation related to chiropractic and physical therapy co-payments. We, and there had been feedback last year to kind of keep those co-payments to the minimum level allowable within the range that's in the current legislation. And we're also aware that there is proposed legislation to move that range even lower. So our strategy here had been to model the plans at the lowest as close to 125% of the primary care co-pay as possible within a $5 increment for the co-pay. So we're not imposing a $43.70 co-pay on anyone for usability reasons. But that does bring it slightly below 125. So we do wanna highlight that. We thought that made the most sense taking the existing law together with the proposed legislation in hopes that we wouldn't have to make changes far down the road in this process. So just wanted to give you that context as well. Of course, it's up to the board how to handle it. And I think with that I'll go ahead and turn it over to Dana to do our overview and dig into the plans. Thank you. Thank you. I'm Dana Hulahann, Diva Plan Management Director and I'm joined on the phone by Julie Pepper, Brittany Phillips and Brooke Adams of Wakely Consulting. They are our actuarial partners who've been guiding us through this process this year and several years before. So we're very grateful to have them. So I'll move on to the forward arrow. To point it at the computer in the house. There we go. Thank you. So briefly, I'll provide this context and overview then turn it to Wakely to bring us through the actual plan designs and more context about the new federal guidance this year and go from there. And as you know, we're returning next week for further discussions, response to public comment, et cetera. So again, for context very briefly, we provided the one page summary that looks this big and busy page like this for reference of the 2020 plans what's currently on Vermont Health Connect. We're here today to talk about the 14, actually seven standard plans. They're the same for both issuers. One at the platinum level, one at the gold, two at the silver, and three at the bronze level that we'll be discussing today. We will not be discussing today but what is included on the sheet is seven additional non-standard plans, two at the gold level, two at the silver level, two at the bronze level, and one per issuer at catastrophic which is not included on this page but just for reference, one to mention it here. So that's the full landscape of the plans. Moving to slide four. For a little bit of review, I just wanna mention our wonderful stakeholder group that we convene in November each year to first review the new guidance as it becomes available and then to discuss the plan design changes that need to be made at each meta level going through the process. So from the state, we have myself and the manager of outreach and education who brings that perspective. We have at least two participants from each issuer who are actively involved. We have a representative from the Vermont Health Advocates Office and staff, at least two each from the Department of Financial Regulation and from Green Mountain Care Board. We have very good active discussion. It's very thoughtful and enrollee focused. I can say that we may not always reach consensus on our final decisions but we have robust discussion and everyone has an opportunity to make their views known and I believe that we come up with better decisions based on all of that input. Again, I won't read this but for our general approach, these are values and principles that we've adopted as a stakeholder group to always bear in mind as we make these changes. Value, affordability, attractiveness, usefulness are certainly very enrollee centric, stability, thinking about the marketplace as a whole and what's gonna be good for the sustainability of our enrollees and easy to explain and not cause any disruption by making changes that are difficult to understand or adapt to. This frames our approach taken for the task of deciding on benefit changes at each plan level. We believe it's important to have these strategic minimal increases rather than perhaps, and you'll see examples of this where there were some plans for 2021 that did not require changes. We opted to suggest minimal changes in the interest of avoiding a bigger change in a future year. Always mindful of the cost to consumers. You'll hear, likely, explain the model that they've created to give us a directional view of the financial or the premium impact of a benefit change and that's one of the important factors that we keep in mind of deciding whether we will implement a recommended change or not. And then of course, consumer education is vitally important. We, as we've said, it contributes to the stability in the market and helps all of our consumers, we believe, to make informed plan choices. So we avoid making complicated changes to benefit designs that are already complicated enough just to facilitate that. Moving on to slide seven, I'm happy to report that silver loading will be allowed again this year and will be implemented in the 2021 plan offerings. This will be the third year that Vermont Health Connect has offered silver loading. We're in good company with many other exchanges doing this. And again, a very brief overview. The loaded premium is for silver plans that are offered on Vermont Health Connect. That's to fund the CSR program that was discontinued at the federal level. That higher premium on the silver level results in a higher benchmark plan, that second lowest cost silver plan that determines the APTC, the premium subsidy, which is the main goal. So our consumers are getting higher APTC than they otherwise would. Those consumers can take those, that subsidy and apply it on a silver plan and also be, if they're eligible, receive CSR or they can take that APTC to another metal level and buy, for instance, if they may expect to be a higher utilizer, they may be interested in purchasing a gold plan at a higher actuarial value using that subsidy. We're seeing a lot of that. It also provides the benefit of an unsubsidized individual market enrollee or our small business enrollees to purchase silver plans directly through the issuers at that lower premium that is not silver loaded. This is for the silver plans. And I wanna point out that the silver loading program has no premium or benefit impact on the other metal levels. I meant to mention as well that what we call a reflective plan, the non, the silver plans that are offered directly through the issuers have one benefit difference, which is a $5 co-pay, a higher co-pay or 5% co-insurance for the silver plans that are offered directly through the issuers. Those are the reflective plans. So continuing that again for 2021, we see is a good thing. Briefly, here's an overview of the timeline. So this month, our goal is to present and get approval for our standard plan designs. In March of this year, just next month, the issuers submit their forms to Department of Financial Regulation. I'll point out that that milestone was moved back a couple of weeks because of the delayed release of the federal guidance. Then as Addy mentioned earlier in April, we expect to get the final federal guidance and the IRS limits on high deductible health plans, not available until then. So if necessary, we will definitely inform the board of any changes to the plans based on the final regulation and if required, come back for approval. Rate approval, excuse me, the rate submission is in May, which goes through several other important milestones with the decision of rates in August. At the end of August, Diva completes the plan certification, the formal notification to the issuers that their, which plans will be offered on the exchange. And then of course, open enrollment for 2021 begins November 1st. We have a lot to cover, so I'd handle that quickly. Are there any questions on the kind of framing and context? One question on the slide before on the unsubsidized solar and you talked about business owners, but can individuals get that cheaper from issuers and do they know that? Yes. So they know they go to, they don't need to have the exchange, they can go to the... Yes, those reflective silver plans are only offered through the issuers and we highly encourage anyone who may be getting, going through eligibility, check up the exchange if they are interested in a silver plan to go to the issuer enrolled directly and those reflective silver plans that lower premium are available to them. Yes. Definitely, and that's, you know, that messaging is key and it's also emphasized in the plan comparison tool. Okay, so moving to slide nine, I'll turn it over here to our partners at Wakely Consulting. They will give us an overview of the regulation changes, including the actuarial value calculator, notes and caveats to the presentation and I want to remind everyone that our, the way we frame our proposal is for each metal level, we provide you a snapshot of the changes to that plan, those plans at the metal level one at a time from 2015 to present. Then we present the view of the current 2020 plan design, our proposed plan design and an alternative and then we also summarize for you the kind of points that led us to that decision one plan at a time. Okay, so I'm on slide nine, Brittany or Julie, I'm not sure which of you will talk us through this but let me know which slide you, you know, when you want to make a change and I'll drive us through from here. Great, thanks Dana. This is Brittany, I'll be walking through the presentation. I think we've kind of touched on the outline on slide nine so we can move ahead to slide 10, which is an overview of the changes to the notice and benefit of benefit and payment parameters for 2021. So the couple items that we've pulled out here to highlight are the first, the annual limitation on cost sharing. So this is the individual out-of-pocket maximum that issuers can include in their plan design and it's increased every year. So for 2021, it was increased to $8,550 from 81.50 in 2020. So this increase of $400 increase is larger than most of the prior changes we've seen, which has typically been around $250 each year. So there's a little bit additional room providing with the $8,550 than what we've generally seen each year. We'll notice this notice in a couple slides as well, but this limit does not apply to the health savings accounts qualified high to death full health plans. There is a separate maximum out-of-pocket for HHPs that's released by the IRS. It's usually released in the spring around April. So we don't have that limit yet for 2021. The other item we wanted to mention is that CMS is encouraging issuers to implement value-based insurance designs. So in the regulations for 2021, this VBID offering is not required by issuers, but CMS is encouraging it. The idea is that issuers would offer lower cost sharing on what they call high value services. So these are services such as maintenance drugs, those sorts of things, high blood pressure or blood pressure costs and monitors. And the idea is that by maintaining these items, the consumer can actually save costs down the road by either similar to preventive, by either maintaining their drug use in order to, and doing those maintenance drugs and keeping current conditions that they have under control in order to avoid some higher cost services down the road. So for 2021, like I said, this is optional. So issuers have the flexibility to adopt some, all or none of the cost sharing designs that CMS included for, because the regulations were released so late and not in line with the current version of the standard plan designs, these VBID designs are not included in our recommendations for 2021, but this certainly could be revisited in future years, especially if CMS continues to push those types of designs. There's also other changes that we have as listed here in the regulations. These are items that don't necessarily impact the plan design directly as the items above. So consider this kind of a really brief overview of a couple pieces of the other regulations for 2021. Can we ask questions on the slides as they go? Sure. Sure, absolutely. So my question is, is there a formula that the bench used to determine $400 increase? What's the process to determine that? Yeah, so it is based on a formula. I don't remember exactly what it is off the top of my head, but essentially it takes the original limit that was placed in 2014 and is ratcheted up each year based on changes in an index value. Julie, I don't know if you remember exactly how that's determined each year specifically. I know there was a change last year to the formula as well. Yeah, I know. There's a lot of different formulas that used for different increases. So we can look at that and get back to make sure we bring that to the meeting next week as well. But yeah, some of them are based on kind of the inflationary factor for healthcare, but I'm not sure if this is one of those or not. So we can make sure that we get that answer for you in the case. Super, thank you. Question, can add a comment. I'm hoping that the Vivid and the value-based insurance design recommendations are incorporated in future years. I see real value in encouraging consumers through cost-sharing for high-value care. It seems to be in line with what we're trying to do with the all-payer model and encourage more crime rate prevention and maintenance of folks on diabetes and all of those things and so if the insurance design supports that, I think it would be really helpful to align any plans with what we're trying to achieve with the population out. I recognize that the time, I'm sure this came out late, I totally recognize that. So I'm saying I hope that we can incorporate that in future years. Yeah, I think just a comment, I think we totally agree that it's a timing issue, but also there's very little information about what they're actually proposing and it is just a proposal. So I think once we have time to see what they finalize this spring and digest it, the timing will work out nicely for 2022. My question about the EBIT was it sounded like from what I haven't read the full regulation, but it sounded like the things specific examples of what they were proposing. Not necessarily that it was, hey, space, or be sure, please look at EBIT, right? So I wanted to ask about that. Is that their approach is to be very prescriptive about it as far as you can tell from them? So from my read, they do list very specific proposals, but none are, there's no kind of, what would you call it, like requirement on the states at all. So it is kind of this broad directive to issuers to explore this. And they do make a comment about they're not sure how it would interact with those state exchanges that require standard plan designs and that that might be a conflict. So I think, you know, there's some room to explore there. Great, the other thing I just wanted to mention is that in 2012, when we were first looking at standard plan designs, we looked at incorporating value-based insurance, so guys, Julie might remember that conversation from a million years ago. And that's partially how we ended up with having certain services be for a child or a lover. Okay, to move on? Yeah. Okay. So on slide 11, just really briefly, an overview of the actuarial value calculator. I think most people are probably familiar with it at this point. But just as a reminder, this is a model that society releases each year. Each year it's updated. Generally, the updates include at a minimum trending the underlying claims to the new benefit year. So for this year would be 2021. But it includes input for various plan design teachers, deductibles at a maximum number of cost sharing for a variety of service categories, including co-vase or co-assurance and whether or not the deductible applies to those categories. It should be noted that the service categories that are included is not completely fully exhaustive. So it includes, I think, about 20 service categories, if most of the major ones, you know, ER, inpatient, primary care, those types of services. But there are a lot of specific service categories that are not explicitly included in the model. Also, there are some sign design teachers that are not supported by the calculator. So if the impact for these teachers is considered to be substantial, the actuary can modify the input to most closely represent the plan design or to modify the results of the calculator to account for these features, which requires an actuarial certification. So just to know, there are some plan design teachers, specifically around the pharmacy limits in the Vermont standard plan design, that do require an adjustment. So you'll see that the output of the ADC has been modified to account for those features in the standard plan design. Again, the resulting ADC from the calculator is really meant to bucket plan designs into the different meta-levels. It's not necessarily the same as the pricing AD that carriers will use to determine their premium. So again, the federal calculator is based on national data as a requirement for all issuers to use the calculator to determine the meta-level. But generally for pricing, carriers will use their own experience specific to the area that they're pricing. And the most methodology of the models that each carrier uses may differ from values within the batch or a value calculator. So I follow up now looking at just the changes to the calculator from 2020 to 2021. This year, the calculator actually underwent some drastic changes in terms of the data. So rather than just trending the data forward an additional year, the underlying plain data was actually updated. So it's now based on 2017 individual small group data that was trending forward to 2021. The 2020 calculator was based on 2015 plain data. So a couple of years older, that was trending to 2020. So because of the change in the underlying plain data, there's some additional movement within the ADs for the standard plan design. This year is then what we've generally seen in the past when the data is just trending and not completely revamped. There were also some changes to the continuous table spending buckets that particularly could have impacted the value of changes in the out-of-pocket maximum for plan design as well. So both of those changes really require all meta levels to be reviewed and to look at potential changes. With the change to the underlying data, the bronze plans are now particularly difficult to meet the AD de minimis requirements based on the results of the draft calculator. So when we get to the bronze plans in particular, we will go through that in a little bit more detail, but we just wanted to note that there's some more changes required to the bronze plans than we've seen in the past due to the draft ADC. Yeah, and then just to visit you, I'm just adding to that a little bit. There have been some fairly public letters to society based on some of these changes and how they're not necessarily in line with most society's intent before. California's is probably the most public letter that was sent. So it is possible that it's our understanding that society is aware of some of these issues. I mean, some people are asking, you know, are they trying to get rid of bronze plans? For example, we don't think that's their intent, but it is very difficult to actually have a bronze plan without the expanded range now. And so one of the, again, just additionally clarify or, you know, caveatting that the actual value calculator is draft, we think it's highly unlikely that they will make any changes for 2021 given the timing of where we're at, you know, and how involved it is to make changes to the actual value calculator. However, it's a possibility, but an unlikely one, but also caveatting that it's possible they'll make changes in 2022. So it's possible that even if they don't make changes and we have to live with the calculator for this year, there might be a little bit of whiplash for next year. So just keeping that in mind. I have a question and kind of a comment. I've always reminded when we go through this process that one of the challenges I think for consumers looking at the changes in the plan design over time is actually driven by the AB calculator based on federal trends and not Vermont specific trends because that means that, let's say we're successful in curbing healthcare costs, that will not necessarily be reflected. It'll probably get lost in the federal data, so it won't necessarily, the trends won't necessarily track when you're then coming up with changes in cost, right? Does that make sense, Julie? What I'm saying? Am I thinking about that the right way? Yeah, agree. And I know sometimes we've talked about whether having this stuff or because the state can create their own actual like, I put it with their own data and their own trends. And so I think in the past it's not really worth it because it is a pocketing tool more so than it is a pricing actual value, but if you get to the point where you can no longer get the plan to pass, that could still be something that would be up to consideration, I guess, for the state to consider. But yeah, we could look to it as a national, but we have a continuous stable, so you have the allowed amounts for each of the metal levels so you could compare those to actual data and Vermont to see how those compare as well. I don't believe we've made that comparison. We do track, but we could do it easily. I don't think it's necessarily for this year, but it's just something to think about. Okay, great. So moving on to slide 13, we just wanted to touch base on some notes from Kabyab in looking at the plan design. As already been mentioned, the regulations in the federal calculator build a draft format. So any changes between the draft version and the final versions of these two documents could impact the actuarial values and the resulting plan design that we're showing here. So based on one comment for you on the calculator, it's possible the final ADC may not be released in full March. I think the regulations and the final notice is probably a little bit later than that, maybe even hitting into April. It can be expected. Also, as I mentioned, the federal HGHP limits are not yet released for 2021. So including, this includes the minimum deductible as well as the out-of-pocket limits. The 2021 minimum deductible and MOOC are $1,400 and $6,900. The proposed plan designs that we're gonna go through for the HGHPs don't currently account for any changes in the deductible or out-of-pocket maximum. So given that we're not expecting changes in the out-of-pocket maximum, or we're not counting on changes in the out-of-pocket maximum that's been conservative and shouldn't be to impact the plan design we're showing here, the minimum deductible would impact some of the plan designs if it were to be increased. But generally, it increases about $50 every two to three years, and it was just increased for the 2020 plan year. So we're not anticipating an increase again this year, but it's always possible. So just wanted to have you out that. And if there are any changes that will impact the plan design, you then, Dana, will follow up with the board knowing any of those impacts. We mentioned those later slides will include an estimated premium impact. So we just want to note that the premium changes that are shown is really just meant to illustrate the trade-off between premium increases and cost-sharing increases for the member. The actual premium change is going to be based on a lot more information than what we've included here, including the carriers models, their own experience. What we're showing for the premium change is based on a weekly benefit model. It hasn't been adjusted for certain benefit designs that are specifically accommodated in the model, such as the embedded drug limit and on the HHPs. And so there's really just a high level of space to kind of show that trade-off that's being cost-sharing and premium. So on slide 15, we have a summary of the 2020 plan designs under the new 2021 draft calculator in that table at the bottom. So the gold, silver, and bronze deductible plans, both with and without the drug out-of-pocket mask are required to make changes in order to meet the demand of its requirements. The CSR plans associated with the silver deductible plan also require changes, but ultimately those plan designs depend on the final base silver plan designs as well. So again, we're gonna go through all of the plan designs at all of the metal levels, even if changes aren't required. We reviewed it to see if changes were desired in order to avoid an AP increase being passed on as premium increases as well as limit some of the increases that might be required in later years if no changes were made today. On slide 16, we briefly wanted to touch base on the chiropractic co-pays. As was mentioned earlier, there is a proposal out to limit the chiropractic co-pay to less than or equal to 125% of the PCP co-pay. The current regulation limits it to between 125 and 150% of that PCP co-pay. So for most of the silver and bronze plan designs, this would require a reduction in the chiropractic co-pay. So even though this regulation is not finalized, we went ahead and included adjustments to the standard plan design to limit it to the nearest $5 increment that's below that 125%. So that should be finalized no further changes that are required to the standard plan design. We also wanted to note that physical therapy co-pays are currently limited to between 125 and 150% of the PCP co-pay. The draft regulation that is out there does not specifically require any changes to the physical therapy co-pay limits. However, based on feedback from the stakeholder group, it's easier and preferable to continue to set the physical therapy and chiropractic co-pays equal to each other. So again, in the standard plan designs that we're showing here, we've limited the physical therapy as well as the chiropractic therapy to that 125% limit of the PCP co-pay. 17, we just have a really brief review of the changes that require green mount care board approval. The certain changes below the limits shown here do not require formal approval. We're showing all of the changes that we're suggesting in the recommended plan designs to be made, even if they don't require that formal approval. So you'll see on the following slide, anything that's shaded in kind of a peachy orange color is a change from the 2020 plan design. Anything that's shaded in green is a change that also requires formal approval. We also have a few changes that are actually a benefit increase for the member, so reduced cost sharing. And so in order to highlight those and point those out, they're bound by a little asterisk. So just as we're going through those later slides, so you know what, each of the different colors and symbols reflect. So now finally getting into the recommended plan design. So on slide 18, we've got just a brief summary of all of the changes that we are recommending in the standard plan design going from 2020 to 2021. As you can see, only a couple of the plan designs actually require formal approval. That's the wrong plan. Both from deductible plans actually. So the one with the pharmacy limit and the one without the pharmacy limit. So we'll go through each of these changes in a little bit more detail as we're going through the plan design. In 19, we start to get into the platinum deductible plan. So as Tina mentioned, the general structure we're gonna follow for the remaining slides going through each of the plan designs is the first slide is gonna show an overview of how the plan design has changed over the years and some of the history of it. The next slide will include the 2020 plan design, the recommended plan design as well as an alternative plan design that was reviewed. And then there's gonna be a third slide that just highlights some of the considerations that were discussed in choosing the recommended plan design. So for the platinum plan, there were actually no changes making this plan from 2014 to 2016. In 2017 through 2019, the deductible was generally raised a little bit each year. The out-of-pocket maximums were also increased a couple of times. And then in 2020, so just last year, kind of across the board co-pay changes were made. So the deductible and out-of-pocket maximums were set equal to the 2018 design, but there was a five to $10 increase in the co-pay for PCC, mental health specialists, urgent care, ambulance, engineer. So really kind of spreading the changes across several service categories. On slide 20, now looking at the recommended plan design for 2021, the recommended design really just makes a minimal increase to the medical out-of-pocket maximum and pharmacy out-of-pocket maximum. This plan design is one of the ones that did not require changes based on the change in the calculator for 2021. There was actually this light reduction in the AZ for this plan. However, as we mentioned, kind of making some of these small incremental changes now can help avoid some larger changes in future years. Additionally, last year because the minimum deductible on the HHPs increased from 1350 to 1400, the pharmacy out-of-pocket maximum was increased to 1400 on the HHPs. So by increasing both of these values, we keep the consistency between the deductible standard plans and the HHPs. And the alternatives of mine, we also increased the ER co-pay to $125. This was really, again, the ER co-pay had not been updated. Since 2014, it had not been increased. So this was reviewed just trying to further limit the premium impact going from 2020 to 2021. Ultimately, the stakeholders preferred the middle version that just increased the out-of-pocket maximum and left the ER co-pay alone. Moving on to slide 22, the goal's deductible plan. So here we're showing the history of this plan design. Similar to the Platinum plan, the design did not have any changes from 2014 to 2016. Since that time, there's been a variety of increases across the deductible out-of-pocket maximum. The co-insurance was increased going from 2017 to 2018. And again, last year, kind of across the board, co-pay increases to PCP, mental health, specialist, urgent care, and ambulance. Again, we're trying to spread those changes across last year across several different service categories, so one wasn't impacted more than others. 23, looking at the recommended and alternative design, this plan is outside of the de minimis range, as is and did require changes in order to meet those requirements, those de minimis requirements. So in the recommended plan design, we increased the deductible $200 to 1,100, increased the out-of-pocket maximum to 5,200. Again, increasing that pharmacy out-of-pocket maximum to 1,400 to e-conceptant with the HHTs. And with just those changes, this plan is in the field just lately outside of that de minimis range. So we also reviewed looking at increasing the generic and preferred brand co-pay. So you can see the difference here between the recommended and alternative plan design. The recommended design has a slightly lower increase for the generic co-pay at $12 versus 15. So the silver deductible plan currently has a generic pharmacy co-pay of $15. And so it was preferable to keep the co-pay on the gold plan a little bit lower in order to try and keep some of that separation between the gold and silver plan design in that case. So both the recommended and alternative plan designs come in at the high end of the de minimis range at 81.9 and 81.8%. The estimated premium impact is actually based on Wavelies model a little bit lower under the recommended plan design versus the alternative which has a slightly lower medical deductible. 5.25, now looking at the silver deductible plan. This plan has seen more increases year over year than the gold or platinum plans. Pretty consistently each year the medical deductible has increased as well as the pharmacy deductible. The auto pocket maximum, the medical auto pocket maximum has increased each year. Last year changes were also required to the coinsurance amount from going from 40% to 50% as well as changes to the co-pays consistent with what we just saw on the gold and platinum plan. So this plan has seen a lot of changes relative to the ones at the higher metal level. So side 26, looking at the recommended and alternative plan design, the increase to the AD on the 2020 plan design was actually a little bit lower with the data changes than what we've typically seen in the past on this plan. So it does require changes in order to meet the demand requirements at 72.1%. However, the changes were quite a bit smaller that were required than what we've seen in past year. So because there were such drastic changes and so many changes to the 2020 plan design, the preference really was to make kind of smaller changes this year since we could. So under the 2021 recommended plan design, the out-of-pocket mask and the pharmacy out-of-pocket limit were increased. Again, that pharmacy limit is consistent with what we were looking at on the gold and platinum plans and making that consistency with the HDHPs. The fiscal therapy and chiropractic limits or co-pays were also reduced from $45 to $40. Again, this goes back to the proposed regulation limiting the chiropractic co-pay potentially to 125% of the PCP co-pay. So that change was made in order to meet that requirement should it be finalized. For the alternative plan design, we looked at also increasing the medical and pharmacy deductible. However, again, because there were so many changes just made in 2020, the preference was really to make kind of the minimal changes to this plan design for 2021 that were possible. Any comments or questions on this? I guess the only question I would have is there any research available that compares the states on each of the different out-of-pocket expenses by the different level levels? Julie, are you aware of any good sources? I'm not aware of any public sources, but CMS does release a public use file that has the maximum pockets for all state health issues. Is that something you could tell us about, too? I'm not hearing any questions, I'm assuming we can keep going. Great, so I'm on slide 28 now. So now we're looking at the silver HHT. Again, this plan has seen some changes, particularly to the medical deductible and out-of-pocket maximums over the years, as well as that embedded single out-of-pocket maximum. So historically, that maximum has been tied to the federal limit that's released. So for 2020, that embedded single limit was at 80.150. Additionally, in 2016 and 2018, the co-insurance rates were also increased, but those have not been increased since 2018. 2021 recommended standard end options. This plan design is right at the high end of the limit in 2020 based on the draft calculator. So again, trying to mitigate some of the changes that may be required in future years. The medical deductible and out-of-pocket maximum were increased under the recommended plan design. Additionally, that embedded single out-of-pocket maximum was increased to 85.50 so that the draft federal limit for 2021, and that brings down the 80 slightly. The alternative plan design looks at a little bit larger increase to the medical deductible. Again, trying to weigh the balance between those cost-sharing increases and the premium increases that you can see down in the very bottom row, the estimated premium increase impact under the recommended design is 0.7% versus 0.5% in the alternative plan design. So ultimately, the thought was to have a smaller increase on the deductible as the premium impact is not being large enough to warrant an additional $50 change in the deductible. I think we're okay. And I'm moving to, oh. I was just gonna say, I think we're good to move on. Great, okay. So moving to slide 31, now we're starting to get into the bronze plan design. So as we mentioned, the changes here, we're a little bit tougher to get within the de minimis range. So on slide 31, we've got the changes that have occurred year over year for this plan design. So similar to the silver, the medical deductible, the pharmacy deductible, the out-of-pocket, the medical out-of-pocket maximum has increased just about every single year since 2014. The co-insurance and the copays are already pretty high as a plan and don't tend to move the AB in the calculator a lot. So those have not actually been increased with the exception of the specialist co-pay back in 2016 and 2017 and preferred brand in 2017 as well. So looking at slide 32, for this plan, the 2020 plan design was at 64.3% and the limit without qualifying for the expanded range is 62%. So with a federal limit of 85.50, it was impossible to get this plan design to meet the non-expanded at 62% limit on the AB. So in order to qualify for the expanded range, the plan needed to offer at least one major service prior to the deductible, so it was the deductible wage. And the regulations list out several different services that qualify for as a major service. So what we've done in the recommended and alternative plan design is we're going to recommend it in alternative plan design is actually wage the deductible, the drug deductible for generic script, which is a benefit increase to the members since in 2020 that deductible would apply to generic prior to the $20 co-pay. The other piece of the expanded, the minimum range is that any co-pay that's applied to the service for which the deductible is waived to qualify as an expanded range, that co-pay needs to be reasonable, which is defined as being less than or equal to 50% of the cost of service. So based on the federal calculator, the average cost for a generic brand script was about $32 in the 2021 calculator. So in order to meet that requirement, the generic co-pay was also reduced from $20 to $50, so that it's below that 50% threshold. So with these changes, the plan design would now be eligible for the expanded the minimum range and could go up to an 80 of 65% instead of 62%. So there's some additional room there. So in addition to increasing, to those changes for generics, the medical deductible and out-of-pocket maximums were also increased under the alternative plan design that medical out-of-pocket maximum was taken all the way up to the federal limit of 85 to 50, and the recommended we've left it at 8,400. This was based on kind of looking at the premium impact and what the difference was in terms of the increase, the additional increase, the out-of-pocket maximum and how much that got in terms of the estimated premium change, as well as looking back at 2020. So in 2020, the draft regulations had an out-of-pocket maximum of 8,200, and in the final regulations, that was actually reduced to 8,150. So there was some concern that that 85,50 may not stick necessarily in the final regulation. So by leaving it at 8,400, there's some room and that this plan design would not need to be updated again once those final regulations come out. Because this plan design is eligible for that expanded AB range, the AB is quite a bit higher for 2021 at 64.1%, compared to 2020 at 62%. So that does result in a larger premium impact than what we've seen on the other meta-level so far. So based on ways of modeling, it's a little over 2% premium impact that we're showing here. Here, I know that's a lot of information to take in all at once. That was an authority. We'll move on to the other broad and predictable plan. This is the one without the pharmacy limit amongst like 34. This plan design was new in 2018. So as far as the history, there's only a few years of experience for this plan. In both 2019 and 2020, the deductible and out-of-box maximums were increased each year. This plan design does qualify for that expanded bronze range as office physics and generics both are not subject to the sensible. Looking at the recommended and alternative plan design, in the recommended plan design, we've increased the deductible and out-of-pocket maximum again to 8,400. With an 8,400 out-of-pocket maximum, the AP was filled just barely over the minimum range. So in addition, under the recommended plan design, we've also increased the generic pharmacy copay from 25 to $30. And in the alternative, we looked at increasing the specialist office visit from 100 to 110. However, a $100 copay for specialists is already quite high. So ultimately the recommended design was chosen leaving the specialist copay alone and the generic pharmacy copay increase. So if you want to mention on the last plan design, we had to decrease the generic pharmacy copay for $15 to meet that 50% threshold and qualify for the expanded bronze range. Under this plan design, we didn't have to do that to generic because the PCP and specialist office visit also has deductible place and those copays are underneath the 50% limit already as is. And the requirement for the expanded bronze range is just that one service has to meet those requirements, not necessarily all services for which the deductible is waived. So I just wanted to make that clarification and looking at the two different plan designs why they look a little bit different in that sense. This is Robin and do you happen to know what the average specialist office visit copay was in the? My mind, but I can pull that and send it over or have it ready for next week. Thank you. Other questions? Yes, I just noticed a pattern in terms of the increase to the prescription out of pocket maximum. And if you go from the trend line from 2014 through the 2021 recommendation, they're all at 1.63%. So this seems that's just what happened. Those are the numbers. Whereas if you look at the changes in the medical out of pocket maximum, they range from a low of 2.64% to a high of 6.78% trend line for the silver. And so it's looking at those over a seven year period. And I'm just wondering if it would be helpful to explain this process to somebody that's not deeply involved in the analysis that we could have just a brief overview of that seven year trend line for these plans and kind of why one grows at a constant rate, which will be the prescription and the others are pretty bumpy. I know there's a lot of bumps in the road here. So, but it's just trying to be able to explain these to people because these are people passionate about this issue and it's just nice to have as much information not only year over year, but for the longer trend line going back to 2014 and it seems the data's here and it wouldn't be that difficult to provide a paragraph on each as to why there's a variance for the medical out of pocket maximum, but not for the drug out of pocket maximum. Yeah, so the drug out of pocket maximum is limited to the minimum deductible for HTHPs and that is based on a Vermont regulation. So because that minimum deductible is not increasing nearly as quickly as the federal out of pocket maximum has been, there's a limit in how much that pharmacy out of pocket maximum can increase. And because we're tied to this federal calculator because we can only increase the pharmacy out of pocket maximum so much because of that regulation, larger changes are needed for other service categories including that medical out of pocket maximum and deductibles and co-pays and so forth to kind of accommodate that limit on the pharmacy side. Okay, I think we can go on. All right, great. So the slide 37, we've made it to the last slide that I had in the Bronx Hyde and Uphill Health plan. So similar to the Silver HTHP, this plan has seen increases in the medical deductible and out of pocket maximum pretty consistently each year. Again, that embedded single out of pocket maximum has been tied to the federal limit. So it has also increased each year and in 2020 was set at that 81.50 limit. So looking at the recommended design options, this, the 2020 plan design is actually within the de minimis range still. As an HTHP, this plan is already eligible for the expanded Bronx range. So this is one of the notes that if it's an HTHP it automatically qualifies for that expanded range. So under the 2021 recommended plan design, we've increased that medical out of pocket maximum from 67.50 to 69.00. And again, increase the embedded single out of pocket maximum to that federal limit at 85.50. However, kind of keeping any other changes very minimal for this plan design. So in this case, the recommended design is looking at a 1.1% estimated premium impact based on a way to leave model. And under the alternative, which basically keeps the 2020 plan design exactly the same with the exception of that increase to the embedded single limit, that premium impact is 1.5%. So looking at making some minimal incremental changes to the plan design each year in order to try and avoid some larger changes potentially in next year or future years. Again, on slide 40, we've placed the table. This is the same one that was back at the beginning of the presentation, just highlighting all of the different changes in the recommended plan design relative to 2020. So again, the Bronx deductible plan with department C limit and without department C limit are the two plans that require formal approval. However, we've listed all of the changes that we've gone through here for reference. Bit of information in the appendices of the presentation. We won't necessarily, don't need to spend time going through that, but you do have that information with you. So that includes the CSR plan design changes. So again, these are limited to the base silver plan design and are determined by that. So we've included those plan designs for reference even though they don't require approval. And then we've also just provided a couple of summaries of all of the recommended plan design options in the side by side so you can see the progression from the platinum metal level down to bronze for all of the different plan designs. Are there any other questions? Okay. Do you have any questions for anybody? Other than the actor or something? Yes. So I didn't catch Kevin's eye at the beginning when we went through the early part. But I do have a couple of questions. Last year, Sean Sheehan, who I know is no longer with you did a very nice graphic that compared to 2018 to the 2019 plans by federal poppy level and also by single couple families, et cetera. And it blended in the advanced premium tax credit as well as Dr. Dinosaur benefits. So it was a very, just a very nicely designed template which I think is still available. I know our Agatha had some, it was helping there. So I'm just wondering if it's possible to, because we have the 2020 data here, but we don't have it in comparison to the 2019. And we also don't have it in a way that blends in the federal subsidies and the Dr. Dinosaur subsidies especially and so I'm wondering if that's something that you might consider replicating for 2020 over 2019. Sure, let me make sure I understand. I do remember Sean doing the work and we might just need to dig up his template. So you're looking for its enrollment information based on federal. It wasn't enrollment, it was, like for example I have here the 2019 over 2018. Oh, great. And you can easily look at this and see that for example for a couple with a bronze plan that with all of their, with the subsidies that are available at 400% of poverty, they're spending 150 bucks a month in premium or 2.73% of their income over the year. Whereas if you cross the line to above 400% of poverty, the premium jumps to $852 a month with no subsidies because there are none and that's 13.8% of that household's income. And this to me is the premium cliff which is noted straight ahead in the Wakeley report that came out December 1st and in there was a proposal that would cost about 2.2 million to kind of fill that gap between 400% of poverty and 500% of poverty. And to me, this premium increase, this cliff is kind of an open wound. It's something that is very small number. If you do the math, there's maybe 20, 200 enrollees that are affected by it but the increase is so dramatic and we have a recommendation now carved out by the actuaries that for the 1.2 million we could provide everybody between, well the enrollments between 400% of poverty and 500% of poverty with a 10% reduction like in their premium and that's something that the eyes don't see why we don't do because it's short money in the scheme of things and it is such a dramatic cliff that making progress towards the good I think is something that we would all like to see. Okay, so I do understand the data request around premiums. I think we're happy to work on that. Can I just clarify, it doesn't sound like it's relevant to the approval of the plan designs for 2021. Is that a fair statement or? I think there are silos here but I think it is relevant. I think that in the beginning the first two or three pages folks talk about affordability, there's another page here where people are talking about silver loading which has a, and how the increase in the advanced premium tax credit was kind of the long, which is a good thing, it was a good thing to do. I just think that as we're talking about plans we should have a conversation about affordability and where that is most salient is in that 400% of poverty region and to me it's not our problem to solve and I'm just wondering, I wanted transparent that that is a problem and B is to talk to folks and encourage folks to try to solve it. Yeah, okay, so we definitely agree about the problem and obviously that's one of the reasons why we commissioned the report or working through the legislature. I will say I'm not sure that we're gonna be able to provide that data in order to inform the decision on the timeline that we need for this set of plans. So I think we're happy to work on that but I just wanna be, I don't wanna over promise in terms of our ability to get that data in this, for this. I think we have a copy of Sean's work that I can send to you. It's obviously gonna take some work to kind of update it but I think the template is pretty well structured. Great, yeah, it would be really helpful to see that. And the other thing I am wondering is why hasn't the department kind of embraced the Wakely, one of the Wakely recommendations in terms of mitigating this cliff and even picking the one which is the cheapest, which is the 2.2 million one that would affect, you know, give people some significant relief. I just don't understand why that hangs out there as a sort of thumb and it's just not being tended to. Yeah, I think I need to defer to the, you know, we put a cover memo on that report when it was submitted this winter. And as you know, as minor as it may seem, there is a significant budget impact and it did not make its way into the budget proposal for this year. So I think we're happy to keep looking at it but I need to just defer to what we have already said in terms of those proposals that were in the report. Well, even my old hat, I have four or five ideas that are pretty simple about how to fund this. And, you know, things like the transition from the state healthcare resource fund to the general fund is a transition from a special fund to a general fund. The special fund interests is earned statutorily and I've double checked and that still stands for the healthcare resource funds and the general fund. That interest just goes to the general fund and it's not preserved for, for benefits. There's other things like the author's report on Dr. Dinosaur, which is a $2.4 million fix that the staff said would be fixed 24 months, which was 12 months ago, so the timing there makes sense. I just know that where there's a will, there's a way these things can be fixed and that this is not in the context of Diva's budget dropping from 245 million in 2019 to, I'm sorry, 745 million to 711 million. The windows at your back now, your caseloads are dropping, your appropriations are, you know, are being made available somewhere, that money's going somewhere and I just, I just, I can't get my arms around walking away from these people that are facing this cut. Here, are there other questions? I just got a quick one, I'm sensitive to some public comment we received last week or two weeks ago about the number of plans and sort of worrying about information overload for consumers, so I'm wondering how you, you know, have arrived at the number as the optimal number in 2018? Yeah, much thought that's a feel-it-the-right number for consumers to digest and choose from and all of that. You talked about the history. Yeah, we've incrementally added a couple of plans over the years in a very conservative way. We've not been in a position that yet to sunset any plans, but I don't know that we've all either arrived at the, what's the right number, you know, especially in the bronze area, we wonder sometimes if there are too many, but it could be disruptive to the market to sunset any, but that's not to say we wouldn't look at that. But the original number of plans is longstanding. Yes. So it's just for the history of the program, we've had the same number of plans and we've only added, we've added a few bronze plans because of the issue with the prescription drug out of pocket preventing, potentially preventing us from making compliant bronze plans and allowing for other flexibilities in that design. So I think that's where we added a few, but otherwise it's been pretty status quo, right? There was a non-standard gold and non-standard silver added over the course of the time. Non-standard is right. And the non-standard, your chosen addition to my recollection was that that was a very popular plan that would sunset the first year and we got a lot of consumer demand for that, because those were the plans for the deductible and out of pocket maximum of the same, right? Right, yes. And so that was added because of the amount of contacts with, quite frankly, the Governor's Office and people saying, why did you take away this plan and I loved it. First one at the gold level and then one at the silver level, came back. Do you think that now that there hasn't some, some of the stability of the types of plans and even the changes that are being suggested here on a minor in many places, how do you come back to consumer understanding of what their choices are? Has that improved over time? Does anybody mention that? Just to get a sense of people really understand the choices that they're making. There are always a lot of moving parts, I think, with consumer education and all of the things that do change. So I think looking at the, you know, always consideration of the right number of plans is important. And I would just add, I think that the consumer education piece has changed a little bit. I think in the early years of the program, we were, for operational reasons, largely encouraging people to stay where they were. And over recent years, because of the influx of subsidies through silver loading and we've kind of changed the message to be really examine your options and put made tools available to facilitate that, including the plan comparison tool that Dana referenced earlier. So I think that it's been a bit of an evolution in terms of the consumer education piece. And, you know, maybe if we find some stability with the subsidies, which is that's always the question, maybe we are at a time to kind of reexamine the numbers. But I think there's a learning curve. Is there a way to measure the use of the plan comparison tool over time and a lot of people using that and feel like there's been upward trajectory at the most recent? Yes, we do have that data and there has been indeed an upward trajectory. I don't know where the most recent numbers have been published or that we put anything out for this past open enrollment, but we typically do a report based on open enrollment. And so I think that's something that we would include in there sometime during this first quarter. Thank you. George. Anything else on the board? Now we'll open up the public, the comments, seeing none, I'll thank you for the presentation. We'll be back at this topic soon. Okay, and we've noted the questions and take away. So thank you for your time. Julie and Brittany, I think we're all set. Great, thanks. Thank you. Is there any old business to report this time? Seeing none, is there any new business to report? Seeing none, is there a motion to move on? Good move and seconded to adjourn. All those in favor, second aye. Aye. We can close. Take care, everyone. Have a great rest of your day.