 Good afternoon, everyone. Welcome to the three-part care board meeting. The first item on the agenda is the Executive Director's Report. Thank you, Mr. Chair. I wanted to update everyone on our schedule. For next month, we have a very busy month on top of what's going on across the street at the State House that makes for very interesting time. But I wanted to let folks know that our schedule is posted online on our website, but for a review here, I will let you know that on Tuesday, February 4th, we have a data governance council meeting that is located in this building on the fourth floor in the conference room. And then on Wednesday, February 5th, we have our regularly scheduled board meeting in this room. And we have quite a few things on the agenda. We have that Act 53, HIE Consent Implementation potential vote. You've heard about that last week. We have the vital FY 2020 budget adjustment and potential vote, which you've also heard about last week. And then you'll also have a non-standard QHP qualified health plan design approval process in 2021 evaluation criteria potential vote, which you'll hear about today. And then last, but not least, you'll hear one care of Vermont's Neat Primary Prevention Program and Overview of Rise Vermont Expansion and Outcomes Measurement. So it looks like a lot of people, but it's three votes and then one presentation. And then on Monday, February 20th, February 10th, we have a general advisory committee meeting. And that is located in that same room here in this building, but on the fourth floor again in the conference room. And then on Wednesday, February 12th, we will hear standard qualified health plan designs presentation on Wednesday, February 19th. We're going to hear from University of Vermont Medical Center of milestone report on investments towards increasing mental capacity. And then we'll also hear the standard QHP designs discussion. And actually that's a potential vote we've heard it the week before. And then for the last item on our next month's agenda is on Wednesday, February 26th, we'll hear the hospital operating performance FY19 year end report. So for a short month, we packed it in. There's a lot going on. And I just recommend you consult our website for those meetings. Thank you. Thank you, Susan. The next item on the agenda are minutes of Wednesday, January 22nd. Is there a motion? So moved. It's been moved and seconded. We'll move the minutes of Wednesday, January 22nd. 11 additions, deletions, or corrections. Is there any discussion? Seeing none, all those in favor signify by saying aye. Aye. Any opposed? So now we're going to turn it over to Amron, Dana, and Emily. And we're going to talk about non-standard QHP. Good afternoon. My name is Amron Abertailey, Associate General Counsel at the Green Mountain Care Board. I'm here with Dana Houlian, the Director of Plant Management and Enrollment Policy of the Department of the One Health Access, and Emily Brown, Director of Rates and Forms at the Department of Financial Regulation. So today we're going to talk about non-standard qualified health plan approval process, as well as evaluation criteria that the board may use for evaluating 20, 21 more non-standard qualified health plans. Before we get into the process itself, I asked Dana if he could provide a little more information about what non-standard qualified health plans are and how we got here today. So I'm going to turn it over to Amron. Thank you. This may be well known by many, but for any of us in the room who are less familiar with the distinction between standard and the non-standard plans, is that the simple answer is that standard plans are offered the same cost share benefit amounts for their plans between the issuer. So in Vermont, the Blue Cross Blue Shield standard platinum plan has the same benefits in terms of cost share amounts as the MVP platinum plan. For example, rates are different, but the benefits are the same. Non-standard plans, that's an area where the issuer has some choice where they can alter certain benefits still within the appropriate actuarial value ranges, but it allows for the issuers to respond to demand their hearing in the small business community. For example, for businesses that they work with or from the individual market, things they're hearing elsewhere in the industry that they want to consider in one of their plans. And as I said, the benefits, although they need to conform to the compliant actuarial value ranges, the benefit configurations themselves can be different among the issuer. So since the inception of Vermont's exchange, we've had both standard and non-standard plans. I've been expecting that that will continue. And today we're here to get more definition around the approval process and criteria for the non-standard benefit designs. I work very closely with a stakeholder group, including the issuers and other stakeholders to present to this board every year. We have the standard plan designs that we propose and that same structure doesn't make as much sense on the non-standard side because the issuers themselves want to make the, you know, introduce an innovation or an idea that they think will be popular in the market and so it wouldn't, you know, it just doesn't fit with a stakeholder group in the same way that we have standard plans to. And actually our issuers have both asked for more clarity around the process for non-standard plan approval. So we've come together to do this as Amron said. So I think at this point I can turn it back to Amron for more detail around how the proposed process was developed. I also just wanted to clarify one item, when we talk about benefits in this context, we're talking about the cost-sharing structure unless so what coverage the policy itself provides. So this process is entirely focused on cost-sharing deductibles out of pocket maximums and does not cover what services is or does not cover another particular plan. So talking about how we developed this process and considerations that we took into account as we tried to come up with a process that would work both for the regulators as well as for the carriers and for the public. Some of the things that we kept in mind was that this really is an area for a carrier innovation. So we wanted a process that would provide an annual opportunity if carriers wished to update their plan designs or offer a different plan. And the idea behind this was allowing carriers as David mentioned to really tailor their cost-sharing plan designs to the priorities and needs of their particular membership. Another main consideration for us as regulators was to make sure that whatever process we come up with is going to work for all of the regulators both the Remount Care Board, DFR and Duba as we have a process for certification that is one of the handouts that you received today. So we wanted to make sure that this process fell in line with that process and that we weren't creating any barriers to things moving forward as they normally do from year to year. Another consideration was transparency in the process. One of the tricky things about the non-standard plan designs is that these are particular to each carrier. So they want to be able to develop these in a way where their plans remain competitive and that proprietary information is kept proprietary. So we wanted to reflect those concerns from the carriers but we also wanted to still allow for some sort of public process and public presentation of these designs. And then lastly, we were looking at this process with an eye towards ensuring minimal disruption to policy holders. And this process as we were developing it includes a time for carriers to discuss with Duba and DFR potential issues that might come up with their standard plans either in terms of forms or in terms of a certification and allows for conversations like hiring to plan map members who are moving out of a plan that's not setting into a new plan to ensure that that is a relatively streamlined process and that there is not disruption to the plan. I wanted to have this slide in here just to highlight all of the areas that the three regular entities have during this process. I won't go through them in detail but they are here if you would like to review them. In this instance, what we're really talking about is the first bullet point for the rebounding framework which is reviewing and approving qualified health plan designs. And so our focus today is on that but I just wanted to give you the broader context of how many regulatory processes are moving through getting qualified health plans on the exchange. I've included three slides that have a higher level simplified version of the process that you have also at the handout. So I will just briefly walk through each of the steps. So roughly a year prior to form filing, the board has the opportunity to update the criteria it will use to evaluate whether a non-standard plan design has value to the framework. Prior to form filing, which typically happens in March, issuers need to notify DEVA of any modifications to non-standard plans or any new proposed plan designs. Following that notification, DFR and DEVA may need with issuers to work through potential form filing or certification concerns. And in the event that the issuer is proposing to sunset a current plan, the issuer must provide DFR and DEVA with a preliminary plan for mapping current and release into a new plan during open enrollment. Number five is sort of a big one for the purposes of the board review. There is a, we are setting a threshold for what plan design changes will come before the board. And what we discussed and have included in here is that if carriers wish to do changes that are considered uniform modifications under federal regulations, then those plan designs would not need to come before the board for approval. This is similar to the standard plan design process that the board does where the carriers also, the board's approval is not required for uniform modification changes to a plan design. Next issuers will present the designs that require the approval to the board no later than April 15th. And another important note for carriers is that all of the plan design conversations that are happening between carriers and DFR and DEVA prior to form filing will be considered confidential so that carriers can feel free to develop their plans without concern that they're going to use a competitive advantage. Once issuers come before the board, they must demonstrate the value of the proposed plan or plan changes. And as part of what we're looking at today, the board will use evaluation criteria to evaluate the value of these plans. To evaluate the value of these plans. To determine the value of these plans. And then we put in there that issuers will have 30 days notice of when they need to present any non-standard plan design changes. Once the board has reviewed the plan designs, there are two options of work and approve the plan designs or the board can decide not to approve a plan design if it determines that the plan design will not add value to the Vermont marketplace. If the board decides to not approve a proposal, the issuer may request that the board reconsider its decision and they have 10 days to request that reconsideration. Or they may refile forms for its current non-standard plan design or that current non-standard plan design with minor changes that don't exceed a uniform modification. And just towards the end, we just wanted to make sure that everyone is clear that the board's approval of a non-standard plan design does not mean that DFR will approve the forms or that DFL will certify the plan. This is strictly for the board to determine whether the plan would add value to the Vermont market assuming that it needs all other requirements under state law. So that is all I have for the process. I think unless there are any questions that anyone has right now, I'll move over to the evaluation criteria and then take questions at the end but I will defer to the chair on that. I do have a question related to the uniform modification requirement. And you don't need to answer this right now but it would be helpful to get a little more detail about what that sort of means in terms of how significant a plan change that would be. And the other question I would ask you to think about a little bit is if there were something, so this kind of goes to the evaluation criteria but if for example we're picking a plan because we felt like it met an evaluation criteria of an innovation in the market. So let's say a wellness plan for example. I think there, I personally wouldn't want the carrier to necessarily then take away that part that made it special even if it was within that uniform modification level. So I'm sorry I didn't think about this prior to today or I wouldn't have given you more of a heads up about it but if you could think a little bit about that over the next three years though. I mean you're welcome to answer that. I don't want to put you on the spot. I could just tell you Emily Brown from DFR last year when we were going through the review process for the non-standard plans. An issue arose where we had a plan submitted that we didn't view as a uniform modification. When we were deciding whether it was usually a uniform modification is a change that's made to comply with the AB value of a plan. So your cost share last year was $1,200 deductible and based on the new AB calculator you need to adjust that to 1,300. That would be a plan design change that would have been done so that your plan could still stay at the level it was. So an example of something that we would view as a non-uniform modification and I think is viewed at the federal level as a non-uniform modification would be a change that was made to a cost share structure. So you had a plan that was mainly imposing a cost share through deductibles and then you switched to a plan that is imposing a cost share through co-insurance mechanisms. So that would be something that would be we would view as a design change and not just modification to stay within an AB range. Okay, great. Thank you. You're welcome. That seems broad enough to be my example. Okay, we'll move on to the evaluation side. Okay. The evaluation criteria before we look at the criteria itself at present the board does not have criteria. So if carriers were to read my slides because I made this up very nicely here. So this proposed criteria would apply to non-standard plan design proposals presented to the board for the 2021 plan year or after that year. Carriers are presently developing their 2021 plan designs. If plan designs require board approval, carriers would present their designs to the board this spring. This criteria adopted will be used in the board's determination of whether proposed non-standard plan design will add value to the long market place. As I have mentioned before, DFR and DVO will be responsible for determining whether plan designs meet federal and state requirements or qualified health plans offer on the exchange. So some of the things we considered when proposing this criteria, we thought that the criteria should provide metrics to the board to assess the value of a proposed plan design in whether we'd add value to the long market place. We also wanted to make sure that the criteria were specific enough to provide guidance to carriers on how they might demonstrate evidence of value. As non-standard plan designs are an area for carrier innovation, the criteria need to be specific enough to allow for meaningful board review, but also broad enough to not inhibit carrier innovation. At present, there are no criteria in place, and one of the reasons we wanted to have to propose criteria is that if carriers decide that they do want to propose something beyond uniform modifications for the 2021 plan year, we wanted the board to have criteria that will provide structure for the board's review. So the, and I think I mentioned earlier, the form filings for 2021 plan are due in March, which is why we are proposing this now to make sure that carriers have a little bit of time before their forms are filed to consider the criteria. The criteria that we are proposing are, first, a substantial difference in deductible and or a maximum out-of-pocket compared to standard plans. Substantial cost share difference for one or more highly utilized services compared to standard plan designs. Plan structure difference compared to standard plan designs, enhancing innovation, or adding value to the Vermont individual and small business health insurance market. As I said, these are fairly broad, but given that carriers are already a good ways into designing their plans for 2021, we wanted to make sure that for this year, we weren't boxing any of the carriers in and that the board would still be able to also have something to look at when we're reviewing plan designs this spring. Steps for both the process and the criteria, we have open date public comment period that runs through February 3rd, and right now the board is scheduled for an assessment potential vote next Wednesday on the 5th. For the moment, staff is recommending approving the non-standard 2HP design approval process and 2021 evaluation criteria as presented that is, of course, pending receipt of any public. Any questions? We'll be happy to answer them. Questions for the board? Tom? So I'm just trying to follow the money here a little bit and I know there's this wall between plan design and then the pricing of the plan design. You know, I appreciate that, but I also think they're inextricably related. So just kind of starting from the top down, the QHP plans, both standard and non-standard, occupy about 67% and had over the last from 2014 to 2018, 67% of the premiums in the situation of Blue Cross Blue Shield, I had a look at, and you'll end the debate. And in two of those years, Blue Cross Blue Shield have lost money and in two years they gained money. Their loss in 2018 in total was, anyhow, the loss associated with the QHP plans was 10.2 million and in 2016 it was a loss of 15.3 million. They made money on the individual small group in 2017 and 2015. So, and as we went through the rate seven process last year, solving some of the big issues and that pushes up the overall cost to consumers, whether you co-paste the Dr. Wood or premium. And I'm just wondering how this process, this process can be leveraged to get more certainty that what we are pricing and the application of the pricing system doesn't result in pressures to raise premiums, raise deductibles, raise co-pays. I was looking at some of the National Association of the Choice Commissioners data, which, and also our actuaries data that said that the MLRs for the small group and individual market, you'll look in the low to high 90s and when you kind of do the math that doesn't leave enough to pay for the administrative expenses and to solve some of the solvency problems. And so I just wonder how we can avoid and how this process might be managed so that we don't kind of wander into a situation where we're spending beyond our means and to the ultimate detriment of people out there needing insurance and it just buying more and more and more affordable. So I think that's a really good point and the feedback we've received from the carers is that they want to innovate or create new product designs to try to attract new people to the marketplace. So, you know, to speak to a plan that was submitted last year, I believe it was submitted in design was proposed to try to attract small groups that actually had left the market for the association health plans and to try to get them to come back with a design that looked very similar to those plans. So that would be a way that by innovating and leveraging the remount care for a process for looking at what the value is to the market, I think that could be a plan or an idea that could essentially help premiums by the subsidization of the individuals by the small groups. So I think that would be a good example. So, and I guess, so as you go through this process, you know, they're kind of in terms of the QAQ population. There's really two markets. There's the non-standard market and the standard market. Is there a process by which are you aware that the insurers themselves are kind of looking at these still pipe book of businesses and trying to sort out which ones are the most cost-effective and which ones aren't? Because I'm just wondering if there's, you know, what the, if there is any cross-subsidization going on between the standard plans and the non-standard plans that we're, it's just invisible to us now, but maybe shouldn't be. That's a good question. And I'm not personally aware, I don't know, but that would be a great question for the insurers. I would agree that the issuers have the most control or the set of information needed to weigh the value of adding an innovation to a plan that's going to attract membership, which we, they want, we all want, and also not have an effect on premium that serves to hurt that. I think the, you know, we all have to remember that the federal AB calculator applies to both the standard and non-standard and their very strict guidelines so that an issuer wouldn't be able to take away any kind of a benefit that would drop or raise an AB value to bring it out of those very tight ranges. So the innovations in plan design are very important, but the AB restrictions still apply and the issuers have their own way of predicting the premium, the likely premium impact based on a tweet, just as we try to do that for the standard plan design of both, maybe using some different methodology, but trying to look at least what the directional impact would be of making this change or that change. So a lot of factors, it's a really good question, but it's difficult to get our arms around all of it. So I'm just wondering, one more question on this issue that as time goes on and we go through the review process, the issuers are predicting these loss ratios and if you look at the actual track record now and the review mirror, they haven't done a very good job in that the plans have lost more money or cost more premiums than they expected. And I'm just wondering who's responsible for that after it happens, does it come to the board and we have to raise rates or should we be, because the insurer is saying we have a solvency problem or should we be saying to the insurer, the solvency problem is your problem and it goes all the way back to plan design and to the pricing of the plan and that's an issue that you have to solve of insurer. I don't know what the answer is to that, but I just feel that some of this is getting formed between the cracks. The other question I wanna talk about a little bit is about the benchmark plan and I know that the 2021 benchmark plan is what it is. I'm not an expert in this area, but my understanding is the benchmark plan that we have goes back to 2014, which predates the law care model and a lot of the kind of current reform efforts that we're engaged here in Vermont. And I'm just wondering, you know what, and the one that sticks out to me the most is pre-diabetic prevention in that you can go to the and the doctor can say, you know, if your number's getting a little high there, you're pre-diabetic and before you get to be a diabetic, it's better to get you on a different track. And what is the best recommendation for that while it's nutrition and physical fitness? And the blueprint does have a program for that that is, you know, barely funded by it, but it is out there in some possible service areas. So, but there's nothing in the benchmark plan that offers an individual the right solution for the CDC diabetic prevention program. And so I'm just wondering if for the 2022 process, should we be looking to revisit the benchmark plan to make sure it is sufficiently and maximally aligned with our other goals in healthcare in terms of the all-care model. It's, you know, if you look at Blue Cross Blue Shields marketing information, they say that once you kind of cross the diabetic threshold, it's about 7,400 bucks a year in terms of the plan that they have to manage that. And from what I understand and what I can see in the blueprint, it's a few hundred dollars a year to have people engaged in a nutrition and fitness program. And so it just seems to me we're being penny wise and not foolish here in some ways. And that maybe it's time to open up the benchmark plan. I understand from those examples, that it could be a bit of a food fight. It could be a bit of a food fight because once you open that door, a lot of people want to rush through it. So maybe the board would recommend that we look to reopen it for the 2022 process, but only do it for purposes of alignment with all the all-care models and not your hearing aids and all these other things that the people would try to squeeze in. Is that something that would make sense to you? I think that's a really good thought. And I think going back to the innovation piece, I think, you know, whenever I go to the NEIC, the national meetings on insurance, a lot of the issuers in the community are talking about management of chronic illnesses and diabetes. So I could see also that innovation, maybe it's not through the state setting a standard for the benchmark, but maybe an ask of carers to try to innovate, to create through utilization management or another technique a process whereby they could adopt some of the state goals into the non-standard plans and maybe effectuate it that way. I can't really speak to whether opening up the benchmark would be a good idea, not knowing what the proposal would be for that, but I could see the innovation, the carriers coming up with an innovative way to try to approach that would also potentially be a good idea. So it just seems to me that we might be stuck with a benchmark plan that's getting a little old. Yeah. And it might be timely to visit it because a lot has happened since 2014. Definitely. Okay, other questions, Jess? Actually, somewhat related to what Tom was saying, I'm wondering, any consideration go towards adding a criterion here that just basically says something like plan design should support current health reform efforts in the state? I mean, we may not have all-payer model, but just current health reform efforts in the state and then that's a criterion we might consider. Any thoughts on that? I think we could interpret Enhanced Innovation as being inclusive of that. Maybe. But I think being more specific that this is up to the state because innovation can be defined glossibly. Sure. So, I don't know, just hook up. All I'm saying is I wouldn't have it be a separate criteria, I would be clarifying for that criteria, otherwise your innovation versus health care reform. Yeah, you can kind of review that score. Yeah, that would be my suggestion. I did, but by the way, I will, let me add, I don't know that we've actually talked about this amongst ourselves explicitly, but I thought of the criteria in a way that one plan proposal might take off several of those boxes. So you could consider something both innovating as well as, I guess what I'm saying is that I think you could have them separate if you would like or one can clarify the other. And we could have those as two proposals for next week for more discussion if that would be of interest. Other questions from the board? I don't have a question, but I have a clarification on the, I don't know, okay. So I'm going to quibble with their, at present there are no criteria in place having been the person sitting in your seat getting the previous criteria approved by the board. So from my perspective, there were criteria that were approved through a process using an RFD that FIBA issued and that absent those criteria being revoked that those are still in place. So that's a legal quibble, but I think it's, for me, it sort of sets the record straight in terms of the fact that it's not like there wasn't a previous process that was followed. That is correct. I misworked that in my slides. You know, I think that is important thing to point out and also- Is that a legal term? We did reference them as well. I knew. And actually that is where that prior approved set of criteria is these criteria. So thank you for that. Yes, I should not have worded it that way. It's okay. That's it. That's my question. Not to open it up to the public for comment. Yes, Walton. Just, but I kind of want to back up something that Tom said and then go a little further with it. I'm curious what in plain English or plain language the phrase adding value to the Vermont marketplace means and to follow up for who? Value for who? Because everyone knows that the idea of a marketplace is positive cash flow to enhance that and you do that through plain denials and through the cost sharing. And more and more Americans cannot afford for more and more Americans with health insurance than for the act of healthcare because of these cost sharing that are forced on by plants like these. So I'm curious, we're adding value to the Vermont marketplace actually means for who? But it's not us. Well, it does say to the one individual in small business health insurance market. Well, I can tell you what I was thinking about when the first time around 2012 on that. And the, so the idea is that in the carrier, so again, this is within the small contained world of cost sharing inductibles with this data mentioned are largely driven by the federal law. So the federal law requires that AD levels which by your definition, if I frankly would be including some unaffordable 10s and very high cost sharing, you can't meet the Vermont level without that. That's a required federal provision. We don't have some problems with that. So adding value I think in the marketplace would be through some sort of cost sharing design which I think it does apply to the consumer or the small business owner. We find it's meaningfully different from the other plans in the given of another choice that they would prefer. So that's how I think about it. Again, it's not gonna solve affordability issues because it's within this small context where we have some authority on the federal scheme. But it doesn't change the federal scheme. So that would be my answer. I would respond also that we struggled with that as we were working through the descriptions of the criteria and we landed in a place where we wanted to keep it high level enough but the issuer is the burden of the issuer to explain what's the value and to who, that's very important but these plans are being proposed and designed by the issuers who would want to answer that question based on their research and what they're hearing from their consumers. A popular example from the 2012 process is that carriers included wellness programs within the non-standard plans that were not included in the standard plan. So that was a design feature that they were arguing added value even if it was a neat type of program. Can you have the follow up on this, Kim? I have the paper off so I'm gonna have to get it. I appreciate your evaluation of our criteria and I can overall really follow up as far as any value in having a substantial difference in standard plans that's not included. And I just want to just suggest that across and one more I should make here should be a look at the overall number of plans so that because I think the more plans we get, the more overwhelming the issuer is trying to pick a plan and at some point even if each plan is substantially different from the next it's just overwhelming. So you could put all these criteria and end up with a hundred still under different plans. And so it just seems like one other thing to consider is are we keeping to a reasonable number of plans so that consumers aren't looking at 20 different plans so what they're trying to say, what you think. Okay, other public comment? Seeing none, I'd like to thank you guys. Ooh, goodness of me. Thank you very much. At this point, is there any old business to come before the floor? Seeing none, is there any new business to come before the floor? Seeing none, is there a motion to adjourn? I do. It's been moved and seconded to adjourn. All those in favor, signify by saying aye. Aye. Any opposed? Thank you and have a great rest of the day.