 meeting to order. The first item on the agenda is the executive directors report, Susan Barrett. Thank you Mr. Chair. I want to first announce that the Green Mountain Care Board submitted two reports yesterday. One was the hospital sustainability report and the other was the reimbursement variation report. Both of these reports are on our website under what's new also they're under legislative reports and if you have a hard time finding them please reach out to me or Karen we can make sure you find them. I just want to make sure that I thank stakeholders for both of these reports. We we know it was a hard time over the last couple of years to take time to provide input on both of these reports so I just want to thank you for providing your valuable input to our staff as we finished up these reports and submitted them to the legislature. We're really looking forward to the next steps on both of these reports. I also want to announce that we have a couple of public comments sessions going on right now. The first is in regard to the essential health benefits benefit benchmark plan. We heard about that last week and if we could have those comments to the board by close of business February 11th then they could be considered for the potential vote that is that are scheduled on February 16th or March 2nd of 2022. And then I will also announce that we are have been accepting public comments for about the last year over a year on a potential next agreement with our federal partners for an all-payer model. Please send those to us if you have any comments regarding those next steps. We are sharing all those comments with the governor's office as well as our AHS partners as they are leading the negotiations. And then last but certainly not least please take a look at our website for the calendar for February. Our meetings are listed. We have a couple of extra meetings beyond the board meetings. We had one yesterday the data governance council meeting. We also have our primary care advisory group on February 16th which starts at 5 p.m. If you have any questions please reach out. I will turn it back to you Mr. Chair. Thank you Susan. The next item on the agenda are the minutes of Wednesday January 26th. Is there a motion? So moved. Second. It's been moved and seconded to approve the minutes of Wednesday January 26th without any additions deletions or corrections. Is there any discussion? Hearing none. All those in favor of the motion please signify by saying aye. Aye. Aye. Any opposed please signify by saying nay. Let the record show that the motion passed unanimously. So next we're going to turn to a discussion of the health care strategic workforce plan and we're going to receive an update from the director of health care reform Ina Bacchus. So Ina whenever you are ready take it away. Thank you. Good afternoon everyone. Thank you for the introduction Chair Mullen. I would like to give an update with there's been a lot of progress towards implementing the health care workforce development strategic plan on numerous levels both and a number of strategies articulated in that plan featured in the administration's proposals to the legislature. We've since submitting the plan we've recommended support for a program of recruitment retention and training which we are pleased to be working with the legislature on. We've also recommended increasing the dollars available for scholarships for nurses increasing the dollars available for nurse loan repayment and have proposed refundable income tax credit for nurses and nurse educators and further we propose specific strategies as recommended by the workforce development plan to promote Vermont as a excellent place to live and work as a nurse specifically and further there is work underway regarding marketing campaign which would promote enrollment in career and technical education programs and emphasize those careers for health care providers as well as initiatives that have been provided for in the budget proposal to support expanding the availability of housing in Vermont as well as as well as bolstering childcare availability in the state. That's a very high level broad overview of a lot of different pieces that have been proposed to be supporting nurse and health care workforce in the state of Vermont. We are also actively working across departments and agencies in state government to address other recommendations in the report such as convening with the programs of health education to explore the barriers to increasing enrollment in education programs for nurses specifically and we're certainly working across entities to think strategically about how we again attract retain and really advance Vermont as an ideal place for working in the health care field. Do you want to take questions at this point? I can certainly take questions I can provide some more if you're interested in going into detail on some of the aspects of the proposals I'm happy to do that as well. So detail would be great. Give an overview of the breadth of work that's been taking shape since we last talked about the health care workforce development plan. Specific to the recruitment retention and training proposal we're proposing to invest dollars to be available for recruitment retention and training of health care providers. That proposal is for dollars through the Budget Adjustment Act and we're proposing that AHS administer a needs-based program to support providers with recruitment retention and training needs. The program would allow flexibilities for employers to propose how to allocate funding within the terms and conditions of the program and to identify recruitment needs retention needs training needs and other creative incentives that could provide for more interest in working for Vermont-based employers. This program proposal does include a service agreement component where the employer in receipt of the funds would provide those funds to employees contingent on a service agreement. We've proposed a service agreement that could be 12 to 24 months. I think we have to continue to hone in on what that agreement would be as we look to implement if we're successful in implementing the program. That program would look at needs based on vacancy potentially look at having needs assessment based on vacancy rates based on turnover for organizations certainly based on organizing you know maintaining critical capacity to maintain access to care. Additional dollars as I say were as I said were proposed also to support nurse scholarships and would continue and expand upon the existing scholarship program for Vermonters and out-of-state individuals to attend nursing programs at Vermont College's universities and universities. This would include students pursuing practical nursing certificates, associates degree in nursing, bachelor of science degree in nursing all included in that scholarship program and this program also it does it does exist today. It is administered with partnership with VSAC and the program as it exists today has a service component to the program. So for each year of scholarship a year of service is required. Further we propose to expand loan repayment for nurses who live in Vermont and who are permanently employed by by Vermont healthcare provider employers. This program also contains a service agreement obligation to live and work in Vermont for each year of loan payment that would be provided through the program. This again is an existing program. The area health education sector is currently administer nurse loan repayment for nurses and again we've also proposed a tax incentive for nurses and nurse educators. The tax credit credit would be available to those nurses and nurse educators living and working as permanent employees for Vermont provider employers and the incentive would include registered nurses, licensed practical nurses, licensed nurse assistants and nurse educators and finally we've proposed that the agency of human services working together with the agency of commerce and community development leverage existing platforms for marketing the state of Vermont and establish a marketing campaign specifically to draw nurses from other states and internationally and to amplify the full range of incentives for living and working as a nurse in Vermont to include the scholarship programs, the loan repayment programs, tax incentives, the fast track for licensure which I know that we talked about in in the presentation of the healthcare workforce development strategic plan that is a program through the Office of Professional Regulation speeds the path to licensure for persons coming to work in Vermont and the program of marketing Vermont as a place to live and work would also feature the availability of relocation programs to support persons coming from away to live and work in Vermont and capitalize on the high COVID-19 vaccination rate in our state which does which does impact how providers are delivering healthcare. Now I can definitely pause here for for questions or discussion. Super so these are wonderful things and thank you for your hard work on this can you help walk me through the dollars I see the the 15 million and the 18 million in the budget are there other dollars elsewhere? So yes 15 and 18 million were proposed in the budget adjustment act from two funding sources both both for the purposes of the recruitment retention and training program so that's a total of 33 million that was proposed. The proposal for the the nurse scholarship program is for the FY23 budget to include three million for this purpose for the nurse loan repayment the FY23 budget proposal is for two million for this purpose. So it looks like a total of 38 mil? For those initiatives there's also a value for the tax the income tax credit I would certainly urge you if you're interested in exploring this further this could be an area that you might want to speak with with tax department about specifically but I think that you know this too has has is an investment as well. I'm pursuing this line just because I think most people tuning in would think geez that's a lot of money but then when you start to look at 120 million spent by this state and so on and so forth and and our neighbors to the west New York state the governor has a 10 billion dollar healthcare workforce proposal so when you do the math that works out to 494 dollars for every resident of the state of New York and if you did that same math for Vermont you're talking about a little over 315 million that just to to stay competitive with our neighbor to the west so I just bring that up that when people hear these large numbers it's really not large compared to what other states are doing and I did want to talk about the faculty because I was wondering if the administration is considering proposing language that would specifically raise the the salaries for the nursing faculty in the state. We are not considering we're we're engaging in the work that the strategic plan outlined and in fact the office of professional regulation is facilitating a working group to explore the barriers particularly for increasing the number of students that are educated in Vermont and those barriers as stated in the workforce development strategic plan do include exploring the differences between faculty pay and clinical pay as well as looking at the issues posed for the availability of preceptor slots and that work is underway that group met yesterday yesterday evening um or perhaps the date no yesterday yeah I came earlier this week that group met um in the evening uh and and there was a very productive discussion there so that work is going to be underway and that will inform any potential further recommendations in this area. How quickly with those with those recommendations come out? Well I think the group is is is just beginning the process of exploring these issues but understands that there certainly is very much attention on this issue and the will for there to be you know problem solving in this area so I I think that it is it's feasible that there could be some recommendations or some insights from that work that come during the legislative session. I just hate to see this drag out we've known about the disparity in the pay for educators for quite some time and I just want to repeat a conversation that I had with an individual so this is second hand information but I'm told that uh Vermont Tech Williston um only accepted about 20 percent of the qualified applicants this is qualified for the nursing program and you know we're in this crisis and to think that we have these Vermonters that want to um dedicate themselves to a career in nursing and they can't get into um a program it just seems like the quicker we solve these barriers on both the faculty in and on the precepting in you know there's a time lag no matter what but it just seems like if this drags out for another year we've just wasted another year to expand our supply of nurses in in the coming years so that's my concern there. Other board members questions or comments? Yes chair this is Tom Walsh I have some question Anna um you mentioned a couple of the programs that have been existing and I and you may have gone through this before I'm I'm new but I was wondering about efforts to understand their utilization patterns have they been highly utilized or not highly utilized why and if they've been under utilized what efforts are being made to address that so these new efforts are are more fruitful. Thank you thank you for the question uh there's certainly more demand for these programs than there are um than there have been a dollars available to meet the need and so that was um a factor in uh the advisory group that advised on um the healthcare workforce development strategic plan certainly encouraged that um you know programs were uh highly subscribed and that there could be an expansion and increased investment in these programs and both of the in both the case of the nurse scholarships as well as nurse loan repayment these programs have been popular and and utilized again with more applicants specifically in seeking nurse loan repayment than you know significantly more applicants than need could be met. Thank you. Other comments or questions from the board? I was curious about the um interagency task force and sort of the status of that group and we're working across agencies in strategic teams very much task oriented and have been um since you know uh since the report was basically um put into you know put into effect if you will um and that work is increasing um in frequency as we are tackling for instance key issues related to um how we work together uh certainly to promote Vermont as the best you know as as it is or really I was born and raised here and I I'm here now I love living and working here it is a fabulous place um and so I think I can I can truly say is the best place to live and work from my point of view. Other questions or comments from board members? Yeah just two quick ones go ahead Tom. Um I'll be I'll be real quick because I was going to ask the exact question that Robin asked. I'm sitting here looking at page six of the workforce report where it talks about the establishment of the state interagency task force and I remember conversations about wondering you know because it was kind of an ad hoc group um you know what what uh how it would unfold and I I guess I just uh you know um but Robin did me to it it's all yours uh Jess. Okay just two quick questions for you Ina um and thank you it's exciting to see some progress on this front as we know it's an acute shortage. I'm wondering one um when you mentioned the um service agreement duration of 12 to 24 months and I'm just wondering like 12 seems awfully short and I'm wondering if there is um you know what is the evidence out there of the time it takes for folks to sort of integrate into the community such that retention rates are higher. Is there any evidence out there what the duration optimal duration is to basically retain those workers in our communities? And if you don't know that that's fine I'm just that's something I you know when you suggested 12 months it seemed short to me so um I would love to think you know about that a little bit more and then I guess the other question is is there any uh sense in which how much how much is it going to impact the workforce sort of to Kevin's point about you know the dollars invested and I'm wondering for example you know is you know do we know if we had increased you know scholarships by three million dollars how many nurses is that going to recruit into the state or you know for increasing the loan repayment by two million dollars just based on historical experience you know what is the marginal benefit on of that you know in terms of additional workforce and even just thinking about the 33 million do we have any estimates of the cost per recruited nurse that we could back of the envelope calculate how much you know this investment what can we anticipate being the increase in our workforce from these 38 million dollars um and I recognize back of the envelope is all that it could possibly be but I'm just trying to understand how much of an impact it's going to have on our shortage it's a great question I don't want to try to do I I don't want to try to do someone that math in my head right now but I can provide you know I can definitely um provide and it's actually in the nurse excuse me the healthcare workforce strategic plan um at least the scholarship and loan repayment information that the plan captures how much we've had in investment available and the number of scholarships um provided for you know within within the parameters of the dollars available and so um we certainly did look at if you provide significantly more dollars uh then you will in you know be able to increase um the the number of at least loan repayment opportunities or scholarships available I can provide you that um analysis but I don't have it right at the top of my head thank you and that's great I would just follow up on that though that if um and I'm a big fan of scholarships for service I I think it's a great program and I think that you could get a lot more than the 12 months but I I just want to keep uh striking this point that scholarships aren't going to help if they can't get into a nursing program and so we need to expand the capacity um otherwise the scholarship dollars really haven't done anything other than display somebody that would have uh have found a way to pay for it anyways and I'm not suggesting that scholarships aren't a good idea I think they absolutely have to be part of the proposal but I I'm just saying that I think the highest priority has to be able to expand the capacity of the existing programs I I I appreciate that point on the scholarships um on the on the scholarships I do want to uh clarify that the scholarship are that persons are eligible for the scholarship for more than one year of their study and so for each year that they receive scholarship then is the corresponding year of service so if a person is a recipient of the scholarship for more than one year then they do um they do wind up with a service term that is longer than a year um for each year of scholarship received so it does stack up that way so there's a little it's it's not just you get a scholarship and and it's 12 a 12 month agreement I'm curious if the task force had any discussions about possibly um if a student certified that um they couldn't get into a program in the state of vermont that the scholarship could be used for a program outside of the state of vermont and um as long as they agree to the service in the state and whether or not um that idea would have any merit or is it uh just another one of my boneheaded ideas because there's no way to enforce that they actually work in vermont so just curious if that conversation occurred well the again we're we're looking to um provide for increased investment in a current program and my understanding of that current program is that it does prioritize um scholarships first for those attending schools in the state of vermont but that it does not exclude scholarships for those who may be attending out outside of school but there is a hierarchy in the uh prior in in the um criteria do we know what percentage of the nursing students that graduate from uvm stay in the state I don't know that no I I it would be interesting to see you know like castleton there may be a lot of new york students going to castleton because it's not that far from the new york border I don't know and I'm just curious uh you know what the retention of the new students is within the state and I also think that on the other end we need to uh figure out ways to allow for more clinical experience and precepting and and uh you know that may mean some resource dollars to institutions so that they can allocate the staff that they're so short on um to um actually precept with the students versus needing them just to keep the uh um current functions going so I think I think your observation about retention of this of the students who are educated within the state is spot on and that uh as we look at again the work underway to really amplify the all of the package of incentives for vermontras to live and work in the or for nurses to live and work as uh residents of the state and as permanent employees of healthcare providers students are are very much a part of that a part of that audience just so much to do and uh I know you're so busy and uh I appreciate everything you're doing on this so I do wish we had um some more guns to help you but we don't I'm not doing this work alone and I think I shared this in our in our last discussion we really are bringing together and leveraging the resources across agencies and departments I I may be the spokesperson for this particular plan informed by the advisory group but this work is is being carried out in that in that um spirit of collaboration that's been very well practiced um particularly in light of the public health emergency but that is I think it just um uh cooperation and collaboration across state government at its finest okay other questions or comments from the board did you have anything further you wanted to what discuss with us or should we go right to public comment you know I don't have anything further I wanted to provide a general update to where we are um we have made a significant amount of progress with the recommendations in the plan and are continuing with the work to to carry out other recommendations that are are part of the plan and so I'm happy to share that progress with you today I know that the board has likely been following some of that in in the legislature and aware of what's been proposed in the budget adjustment as well as in the budget um on on the workforce front and again that the workforce um workforce and investments in workforce on the whole also contribute to improving the health care workforce like I mentioned and also was featured in the health care workforce development plan we certainly need to invest in those programs that would create more housing availability and and support child care availability in the state both of those things are part of the administration's budget proposal we continually hear about problems for housing for even travelers so it's something that is a huge problem and some areas are better than others but one of the things I wanted to ask you because you talk about the the dollars that are in budget adjustment it appeared like the hospitals were shut out from the house version did that get changed in the senate or are they still kind of left in the dark for some of these dollars I hesitate a little bit to speak to things that are are moving but um my understanding of this senate proposal uh is that hospitals are included there okay so it'll be fought out in conference I I will leave the legislative um expertise to you chair okay so at this point we'll go to public comment and any members of the public who wish to comment please raise your hand I see a couple of hands raised and I'm going to start with Dale Hackett Dale I really wasn't fair to Ina that was putting her on the spot for sure but it was a good question um I love putting Ina on the spot Dale she's an incredible asset to the state of Vermont oh absolutely um no doubt about that um you do really good work you know you brought up an interesting point I just wanted to comment that you can try to grow a workforce but there is a great deal of synchronicity that goes with this um you need to have the ability to if a student wants to go into nursing um there's only a certain amount of time they're young they want to do it now if you tell them that they you won't have a position for them to go to school for another two three four years um that just doesn't work there's no reason it should so I would strongly support any school they can get into that that scholarship goes with them as long as they do come back to Vermont my other comment of many I could make is when they get done that service of whatever it is if they're if they're in school for four years and they have to serve for four years when you get done that for years well we have to think about is do we have the housing do we have the affordability do we have are they all in sync are they all there because as you pointed out the traveling nurse comes in they can't get housing well after they serve why would they want to stay in Vermont they never found housing it just doesn't add up so I just want to point that out that there is that much bigger issue and I don't know how we're going to do that because I don't know how the federal funds are going to go I got there are so many unknowns but it does seem clear what the challenge is that includes the effects of the pandemic on the mental health of everyone a student a student that's in grade school that's going to increase need for workforce within health care I don't see anything moving forward without mental health becoming a really major issue in terms of sufficient capacity for those needs or you're going to have people dysfunctional in a sense and yet skill anyways that's the end of my comment thank you deal some excellent points next I'm going to go to Eric Schulteis Eric hi I just so that was wonderful and I wanted to board member Holmes's comment really interested me and so the national health service corps loan repayment program actually uses likelihood of staying as a criterion for judging how they're going to award those so that perhaps gets at her question I also think I can only I'm speaking from personal experience these programs are exceedingly difficult to navigate for the person I mean the amount of time I've spent dealing with the public service loan forgiveness program is shocking I mean probably well in excess of 30 hours and you know I've read regulations for a living so from a student's perspective I think having assistance to navigate and the healthcare space seems particularly difficult because unlike in the legal space where there's only one program there are four or five federal programs and then the state on top of that and you know I don't know what medical schools do to educate students about it but my law school had zero education on or someone to help you with it I mean it was all on May after I'd already graduated so that's just something to think about that these programs are exceedingly difficult to navigate thank you Eric that's a great point next we'll turn to ham Davis ham thank you Kevin I just have two kind of how many questions I have two comments one gets to your basic concern about getting in nursing school and so forth I think that's the reality is it seems to me is that the huge demand for nurses overwhelming demand for nurses is true statewide it's a national problem and it was just a story in the New York Times a week ago that said that the rate limiting variable there is really not money for salaries for for nurse educators it's the flat-out number of nurse educators and not enough nurses to teach all the people that you would nurses you would need to really answer the the difficulty in the supply line the second is a comment about the overall I don't have any problem with trying to get more nurses trying to you know give them scholarship I'd give them I'd give I'd let anybody in some countries any anybody that wants to be a nurse can go for nothing and so but the reality is it seems to me if we look at practically then the situation in Vermont ice that is it seems to me is that that your chances of actually moving the needle in terms of the need for workforce is very small really small and can take a really long time and what I would suggest is that if you that what if what you're trying what you're actually trying to do is you're trying to find enough manpower or person power to operate a a 14 and a half hospital network for 600 000 people if the reality the reality is you've got you've got way more hospitals you need and you haven't had a whole string of consultants that come in here from Stroudwater from you know from at Mathematica from at least five or six of them and they've all come in there and they've said you're you're you're uh that you're your network a number of full service hospitals is way too high you can you can start to fix that today thank you thank you ham is there other public comment is there other public comment Walter you're on mute Walter the hand wouldn't click so it cut up late just thanks to Eric on his about the navigation of the of the problems of navigation with all the regulations I hear that from nurses a lot especially nurses who are training to be nurses um I do know that system like the NHS National Health Service in Britain which the right wing is now trying to destroy but in any case nurses go to college for pretty much free they practice for a certain number of years and they pretty much stay there and the same with physicians they don't graduate with hundreds and thousands of dollars in debt like our physicians do here I'm wondering if that could factor in to what Vermont is trying to do as Vermont is essentially locked in a comp in a state of competition with 49 other states about hams right this is a nationwide problem as well so I don't it's just a generic question thank you Walter is there other public comment is there other public comment if not we really want to thank you and we really want to thank you for all the hard work that you've been doing not only on the workforce but everything else related to healthcare as things are moving quickly in the legislature and so thank you and we're going to now turn to a discussion with diva in the proposed 2023 updates for standard qualified health plans and I would ask um Dana Houlihan if he could introduce uh the panelists Dana afternoon everybody thank you um I think to start us off I have Addie Strumlow with us and I'll turn it to Addie to to get us started and then I'll turn to the presentation in our our guests on the phone Addie if you're still there I am good afternoon everyone thank you for having us um Addie Strumlow deputy commissioner at the department of Vermont health access I'm just going to provide a few um general remarks and then turn it over to Dana and team to walk through the plan design presentation um I wanted to mention you'll be seeing a lot of diva this winter between the qhp design work and the EHB benchmark update as you know these are related issues but we're talking about different plan years so today we're here to talk about the standard qualified health plan designs for 2023 this year most of the changes are driven by federal activity last year when we were here on this topic the new federal administration had not been in long enough to really impact the process except to kind of slow down the the final payment notice and also to signal the new subsidy program um I wanted to spend just a quick moment on enrollment and the subsidies um we will have data for you next time as is our tradition um but did want to just reiterate that the American Rescue Plan Act subsidies have been implemented they are currently in place through 2022 and they have driven uh somewhat of an enrollment increase for us overall qualified health plan enrollment is still down relative to prior to the pandemic and that's because of the Medicaid continuous coverage requirement during the public health emergency um so that dynamic is still in place uh this year CMS has been very active related to exchange policy they extended open enrollment through January 15th created new opportunities for special enrollment periods that we'll be taking advantage of and they also made significant changes that impact plan design including updates to the AV calculator and other policy proposals related to the demand in us ranges so while we're happy to have the guidance there there have been years when we haven't had anything when we're um when we're coming to you all um but it has been a lot to react to um and really grateful for the work of the stakeholder group and our partners at weekly to wade through all of that so with that I will turn it over to Dana to walk through our process and then to our partners at weekly um on the on the proposed designs great thank you ready so if I can share my screen and get to the presentation can everyone see that I can't yeah can anybody see it now we can okay apologies for my lack of technical ability here so as uh as you know we're here to talk about the 2023 standard qualified health plan designs and I'm joined by Julie Pepper, Brittany Phillips and Brooke Steiner from our partner organization weekly consulting that advises us on all the the actuarial analysis and and modeling leading to this presentation today I'm just going to frame up a few things about our process and then I'll turn it to weekly consulting to go through the details of the federal guidance changes for 2023 and the proposed plan design changes for 2023 as well and then of course we'll return next week for questions and further public comment and as I'm hope for the we'll prepare for the board vote again just for grounding I want to emphasize that we're we are focusing on the uh seven standard plans for today there's one platinum one gold two silver one of which is a high deductible health plan design and three bronze one of which is a high deductible health plan and that's each of these per issuer so both blue cross and blue shield and mvp provide these same seven plans with the same benefits I'll mention that there are also seven non standard plans from each issuer that we will not be focusing on today I just want to point out this this one page document that was also forwarded to you and it's on the diva website this has all of the this is the 2022 page for these are the standard plans where my cursor these seven plans one for each issuer and over here are the non standard or issuer choice plans for blue crossing mvp with rate information at the bottom again a word about our stakeholder group position that I bring together every november to talk about the next year's standard plan designs we have representatives from all three of our issuers we have a representative from the healthcare advocates office and staff a staff person from dfr and green mountain care board so we meet from november through january each year we just in fact finished our stakeholder design work last week so it's a very active discussion with regular meetings and a lot of you know hard work and and thought goes into each of the decisions that we make some years are I would say easier than others and this year with the greater amount of federal guidance change I think it was a little bit more challenging this year than than some others so I won't read these but a little bit more on our stakeholder group values these five terms are very much front of mind for us as we go through our process and in fact in today's presentation you'll see that we have included a proposal for three primary care or behavioral health visits with zero cost share for the for a silver plan or a bronze plan which we think speaks to the principle of both value and usefulness for the plan that comes with tradeoffs as you'll see for other cost share changes that would be required to accommodate that but more detail in that to come in our process as we go through each of the the plans where we make our decision we're very much focused on sometimes a strategic minimal increase is better than not making any changes just to avoid a and kind of an abrupt change in the upcoming year you'll see that actually some of the 2022 plan designs are still compliant using the 2023 av av calculator but in most cases we thought it was preferable to institute minor increases to again avoid something abrupt in the future focusing on cost always both premium impact that's anticipated and also the real dollar impact of the cost share amounts that we're talking about and then we want to always be mindful of avoiding a plan design that could be confusing to customers or for anyone else trying to explain the benefits to a customer a reminder that we will continue silver loading in 2023 to maintain the cost sharing reduction benefits for qualified individuals so again that means that on exchange someone whose income eligible could get a reduction in their cost sharing customers interested in silver plans who are ineligible for income eligible for the CSR programs can get a lower cost silver plan directly through MVP or Blue Cross Blue Shield and just to place a reminder again where this milestone that we're beginning today fits within the the full certification cycle there's a few points here it's this month where we're getting our plan approval for the standard QHPs in March the issuers file their forms which is the contract documents and and benefit summaries to DFR in March the IRS guidance that affects plan designs is expected each spring so as possible we will need to return with some updates to what we have today based on that guidance but we have tried to anticipate what those increases or changes will be so but we will certainly keep the board posted rate proposals are submitted in May it goes through its analysis and you know public hearings and and comments leading to the decisions in early August plan certification is actually completed by the Diva Commissioner we target late August for that which launches all of the preparation work for open enrollment to get the the Diva system and for the issuers to prepare their systems for enrollment in the new year and like I just noted here the usual open enrollment period this end date is subject to change depending on circumstances so so with that I will turn it over to our partners at Wakeley and so then we'll start with a review of the 2023 federal guidance thanks Dana this is great sharing so then you can pull that up great let me go ahead and share my screen this is Brittany Phillips from Wakeley Consulting thanks Dana um I'm joined by Julie Pepper and Brook Steiner as well so I think I'll I'll be doing the bulk of the talking but you'll see their names on here as well um the the plan for today is to talk through the proposed regulation changes um for 2023 inclusive of the notice of benefit and payment parameters and federal AV calculator those are both in draft form so subject to change but we do have some changes to be aware of that have come out in the draft proposals there and then we're going to spend the bulk of the the time walking through the recommended plan design changes that were discussed with the stakeholder group and we've been working on for the last couple months through that so the first item to focus on I want to bring attention to a few changes that came in the draft notice of benefit and payment parameters so as I mentioned this is still in draft form these items could change in the final regulation but as of today the plan designs that we're presenting here are compliant with the draft regulations that were were released so the first item that I want to mention is that they have proposed a change to the AV de minimis ranges for 2023 um so for the the different meta levels there has been a minus four percent or plus two percent de minimis range um on the plan designs for the last several years what that means for a silver plan which is considered to be a 70 percent AV um a plan that actually falls within a 66 to 72 percent AV range is still considered a of silver plan and compliant with this de minimis range um so this tightens the range um to negative two or plus two percent um so for most plans again um a shrinking of the low end of that range that's acceptable um the one exception is actually for silver on exchange plans where they've recommended an even tighter de minimis range that actually goes from a zero percent floor to plus two percent um so again for that silver plan example that I was using this would be a 70 to 72 percent um de minimis range so we went from basically a a six percent overall kind of range to now a two percent range on those silver on exchange plans um similarly the cost sharing reduction plans that are associated with the silver um plan options currently those have a negative one to plus one percent de minimis range so a much tighter range around those plans um under the proposed change that would also have a floor of zero percent so now we're looking at just a one percent de minimis range on those plan designs um so some considerations around these smaller plan design or de minimis ranges um I just want to note that the current Vermont standard plan designs are all um towards the higher end of the de minimis ranges so they're not specifically impacted by this change directly um all of the plans continue to meet the the minus two and plus two percent even the silver plan is is above 70 percent and so continues to meet that that tighter de minimis range but it could limit um options for changes in the future because we do have a smaller range around those those options we are kind of limited in terms of the the plan design changes um potentially in future years um the other item is that the reason for the uh higher floor on the silver plans is likely to maximize premium subsidies available since those are um tied to the silver plan premiums um having a higher AV range on those silver plans um generally speaking should result in higher premiums a higher benchmark therefore used to determine the premium subsidies for members below certain income thresholds um so uh while it maximizes those premium subsidies for the subsidized individuals it could limit options for individuals that are not eligible for subsidies um since they may have fewer options at kind of a lower AV range available to them and potentially lower price points there a few more items that came out of the notice of benefit and payment parameters um federal standard plans were reintroduced for 2023 um these had been introduced uh several years ago I think around 2017 2018 um they were only around for a couple years and then then removed again um so those have been reintroduced uh one difference is that this year um carriers in federally facilitated market in states with the federally facilitated marketplaces um would actually be required to offer the standard plan designs whereas previously it was um noted as an option again this does not directly impact Vermont um being on a state-based exchange and already having standard plan designs in place um there's an exemption for uh for Vermont in the proposed regs but did want to mention it um in case it comes up or or you hear of those federal standard plan designs so we've provided a summary of the federal standard plans and the appendix of the presentation that Dana um provided um but a couple key points that I just wanted to mention in comparing those federal plans to Vermont's plan designs um generally they're at the very low end of the the AV range so um basically at that floor of the demand miss range in across all of the metal levels um so because of that they tend to have higher deductibles and out-of-pocket maximums relative to Vermont's plan designs and the plan designs that we've uh we're proposing here um also generally speaking the plans had combined medical and pharmacy deductibles whereas most of the Vermont plan designs have separate medical and pharmacy deductibles so for members that uh have uh prescription drugs that are um subject to the deductible tends to be a much higher deductible that they have to hit in the federal standard plans relative to the Vermont plan designs um they are similar to the Vermont standard plan designs in that they do have a mixture of copays and coinsurance so generally the copays apply to office visit services coinsurance to facility services inpatient and outpatient services um so in that that's instance they're um somewhat similar again generally the coinsurance levels are lower on the federal standard plans but the copays for those office visits tend to be higher so um there's quite a few differences in in the plan designs but also some similarities we're seeing uh the other item that we wait to to come out in the notice of benefit and payment parameters every year is the annual limitation on cost sharing so this is the maximum amount for a single individual that we can set the out-of-pocket out-of-pocket maximum at um so for 2023 this is actually no longer submitted through the notice of benefit and payment parameters but through a separate guidance letter um so it has been set at 9100 for 2023 which is a $400 increase relative to the 2022 limit of 8700 um so one item to mention there is that is a larger increase than we've seen in the last several years um and also because this is submitted through separate guidance it is final um and not subject to change with the final notice of benefit and payment parameters so that's one item that we actually know is set for 2023 at this point um as Dina mentioned uh we do not have the federal high deductible health plan minimum deductible and out-of-pocket limits yet those are generally released late april or early may each year um so those uh numbers we are waiting on still um the 2022 minimum single deductible is $1400 and the out-of-pocket maximum is $7050 um generally that minimum deductible increases about $50 every two to three years um the last increase was for the 2020 plan year um and the moop increases about $100 every year so the proposed plan designs um for the high deductible standard plans um we have assumed that that minimum single deductible will increase to $1450 um based on the historical pattern um and what we kind of know at this point we think there's a really good chance that that will increase and so we've reflected that in our standard plan designs um there are other changes that that I haven't listed um as we mentioned there's several changes that were released this year these are the ones that are most closely related to the plan designs um the other changes uh have to do with you know may have premium impacts and and other implications but not necessarily on the the plan designs themselves so just a quick refresher on the actuarial value calculator um societal releases a calculator each plan year um right now that calculator is in draft form so again um subject to change with the final calculator although that's fairly rare with the the federal AV calculator um but this model has to be used to determine the actuarial value of a plan for purposes of determining compliance with those AV de minimis ranges and the metal valve metal level of requirements um so the calculator includes several inputs for varying plan design features deductible out of pocket maximum copays for about copays or coinsurance I should say for about 20 different service categories so while it captures some of the most uh highly utilized services it does not capture every single possible service and every single possible benefit so because of that there are some plan design features that are not supported by the AV calculator and in that case if the features are considered substantial you can submit an actuarial certification to make adjustments to the AV calculator output for those features so Wakeley has been doing that for the Vermont standard plan designs for several years there are a few features that are not directly accommodated by the AV calculator the other item that I want to mention is uh when we're talking about actuarial value there's really kind of the the federal AV calculator outputs that are used to determine metal level compliance and then there's also a pricing AV that the carriers will use to actually determine the premiums for these plans so the federal calculator is based on summarized national data whereas the carriers will use their own experience the carriers will generally use their own model and will not use the the AV calculator to determine the pricing AV and as I mentioned not all service categories are reflected in the AV calculator so there are several reasons why the premiums that that the carriers will submit may not directly align with the AV calculator output that we're showing here as far as changes to the AV calculator for this year the 2022 or sorry that should say 2023 the 2023 calculator is in draft format as I mentioned it's pretty rare for changes to happen between draft and final but it is possible so the plan designs that we're showing are compliant with the draft version of that calculator the largest change to the calculator this year compared to last year is that they noted that they actually updated the underlying data so last year the calculator actually did not change from 2021 to 2022 due to uncertainty around the impact of COVID and ongoing uncertainty around the pandemic so this year they actually updated the underlying data from 2017 individual and small group data to use 2018 so more recent year of data and then they also trended the data from 2018 to 2023 to reflect 2023 costs again nationally representative though not specific to Vermont so the table on the right here shows the difference in the underlying data so we have allowed amounts per member per month in the 2023 calculator relative to 2022 these represent both the combination of plan payments as well as member cost sharing so it's meant to reflect kind of the total cost of service on average for the different metal levels so you can see the silver AV or allowed amounts increased substantially of 14 percent increase over last year's calculator and the bronze allowed amounts actually decreased and so the AVs that we're seeing when we run the 2022 standard plan designs through the new calculator are pretty consistent with these changes we're seeing much larger changes on the silver plan plans relative to prior years and the bronze plan designs actually saw a decrease in AV under the new calculator so as I mentioned just a quick caveat the pricing AVs and the federal AV calculator output that those federal AVs are kind of different data points in terms of looking at how premium may be impacted by cost sharing changes so we've provided an estimated premium impact in the following slides this impact is based on Wakeley's pricing model running the standard plan designs through through our proprietary model and and producing a pricing AV output this is meant to be reflective of the the difference between the federal AV results and pricing AV results and is really meant to show the trade-off between member cost sharing at the time of service and premiums but as I mentioned the carriers will be using their own models their own underlying data to determine the actual premiums and so those results that the carriers include in their rate filings the spring may differ from what we're showing here in addition the pricing and premium impacts that we're showing here are really only reflective of the benefit cost sharing differences it does not include several other items that go into premiums such as medical cost trend network changes you know any of anything really outside of the benefit changes that that go into setting that final premium rate okay so starting to get into the meat of the standard plan designs what we are showing here at the table is the 2022 federal AVC results and compared to the 2023 calculator results for the 2022 standard plan designs so the rows that are highlighted are the ones that are outside of the de minimis range just simply based on using the different calculator so the gold and silver deductible plan designs both require changes in order to meet those new de minimis requirements as well as the silver hdhp option as Zina mentioned even when changes are not required generally the stakeholders have looked at making minimal changes in order to help offset some of the premium impacts of the various cost sharing changes and really kind of allow members to be used to you know some small incremental changes year over year versus large sweeping changes in a in a given year so even though the platinum and bronze plan designs do not require changes we are presenting some recommended options that are different from the 2022 plan designs for that reason and as I mentioned we do make a few adjustments to the av calculator outputs that are not supported by the federal av calculator and so those are reflected in the avs that we're showing throughout this report as well so just as a reminder there are certain thresholds for changes to the standard plan designs that require approval by the board so copays less than or equal to $15 coinsurance changes less than or equal to five percentage points deductible changes less than or equal to 200 or out of pocket changes that are less than the increase in the federal out of pocket maximum so again that's $400 for 2023 so while we are showing all of the plan design changes that the stakeholder group has decided on not all of them explicitly require green mountain care board approval so in the following slides you'll see we've shaded any of the changes that we're recommending in kind of an orange color and any that also require green mountain care board approval are shaded in green so this slide is just a summary of the proposed plan design changes that the stakeholder group came to consensus on we will go through each of the plans specifically and through these changes in more detail but did just want to know a summary of the changes that are going to require green mountain care board approval so the silver deductible and hdhp options both require explicit approval as well as the bronze deductible plan without the pharmacy limit so while we're recommending changes to all of the plan designs are presenting changes to all of the plan designs many of them are below that threshold that requires explicit approval so starting to get into the the actual plan designs themselves for each of the plans will follow kind of a similar pattern so to get you accustomed to it a little bit on the platinum plan this first slide that we're showing here is the historical platinum plan options so you can see from 2014 to 2016 this plan design was actually offered with no changes and since then we've made some incremental changes year over year through last year so going from 2021 to 2022 the only change that we made to the plan designs was a 50 dollar increase to the medical deductible all other cost sharing features were maintained for 2022 and in looking at the 2023 option so we have the 2022 plan design that left most column and as as we mentioned this plan does not require changes in order to meet the de minimis AV ranges the 2022 plan design is at a 90.1% AV so kind of right in the middle of that de minimis range however due to leveraging of fixed claim costs so such as deductible out-of-pocket maximums co-pays those fixed costs do have a premium impact if no changes are made it's likely that it will result in an increase to premium so the recommended plan makes some updates to the medical deductible an out-of-pocket maximum you can see shaded there looking at a 25 dollar increase to the deductible and a 100 dollar increase to the out-of-pocket maximum this results in a slightly lower AV on the 2023 calculator relative to the 2022 plan design and an estimated premium impact of about 0.2% so some considerations for for these options were again trying to make minimal changes kind of year over year but but also incremental changes so that larger changes are not required in future years and also trying to weigh that trade-off between cost-sharing increases or cost-sharing changes when a member receives service and impacts to the premium the alternative plan design that we're showing here would actually be to maintain the same 2022 plan design as part of the stakeholder group we you know have looked at several different plan options and kind of narrowed it down to these two to share with you all but really trying to again look at those those trade-offs between cost-sharing and premium you can see maintaining that same 2022 plan design has an estimated premium impact of about half a percent based on Wakely's pricing model relative to the 0.2% if you make some of those incremental changes so really showing that trade-off in your slide deck we also have some kind of the follow-up notes I'm hoping to go through the considerations while we're looking at the plan designs but for your reference after the presentation if you need to go back and take a look at any of those considerations we do have them written down in the presentation so again looking at the historical gold deductible plan changes similar to platinum this plan design did not change from 2014 to 2016 but really starting in 2017 we've made incremental updates to the plan designs for the gold plan year over year and again kind of similar to the platinum plan last year the medical and pharmacy deductibles were both increased on this plan so a $100 increase in the medical deductible $50 increase to the pharmacy deductible as well as a $200 increase to the medical out-of-pocket maximum in looking at the gold deductible plan options the federal AV for the gold plan is at 82.3% based on the 2022 plan design so this plan does require changes in order to meet those de minimis ranges the high end of this range is 82% so we do have to make some changes to this plan design again consistent with the platinum plan the recommended plan increases the medical deductible it also increases the medical out-of-pocket maximum the increase on both of those is $200 relative to the 2022 plan design and again you can see this brings the federal AV down to 81.7% so about a 0.2% increase over last year's federal AV and a similar estimated premium impact based on weekly's pricing model for this plan design the alternative plan looks at further increasing the pharmacy deductible another $50 again this has a lower premium impact but is offset by that additional increase in the the pharmacy deductible that members may may face if you look at the the prior changes we have not necessarily changed the pharmacy deductible every single year and so because it was just increased in the 2022 plan year the stakeholders felt that keeping that at the same level as 2022 was a preference and the recommended plan design versus that alternative plan discussion looking at the silver deductible plan now this plan has had some larger changes year over year generally as we get lower in in the AV ranges the the incremental changes that have been required year over year simply based on the changes in the AV calculator have get more and more substantial so we have previously made some increases to copays and coinsurance on this plan in the most recent couple years the only changes have been to the deductibles and out-of-pocket maximums and really maintaining the consistency in those coinsurance and copay rates for for members over the last couple years and looking at the options for the silver deductible plan the 2022 plan design is at a 72.9 percent AV this is a 1.8 percentage point increase over last year's calculator so as I mentioned when we were looking at the changes to the federal calculator the silver plan was really had the largest impact in terms of changes to the calculator and the increase to that AV so in order to bring this plan down below the 72 percent AV mark it really required some very substantial changes to the plan designs in order to meet those federal requirements I will say that the stakeholder spent the most time on this plan design we looked at several several options so while we've kind of whittled it down to these two options before you there was a lot of discussion that led to these two options being kind of the the final two in the running so this plan design has a $600 increase to the medical deductible a $100 increase to the pharmacy deductible as well as an increase the out-of-pocket maximum up to that limit for 2023 of 9100 and an increase to the ER copay to $500 in both plan design options we looked at you know the potential of doing a co-insurance rate on the ER copay as well but ultimately decided that the stakeholder group decided that the increase to the ER copay was preferable to the co-insurance change generally I think members prefer copays and to know what their cost sharing is going to be but we did review that as it did have a pretty substantial impact on on AV but ultimately decided against it for purposes of these options the first option also has changes to copays so the first thing I'll note is that the PCP and mental health substance abuse office visit copays this plan design would offer three free visits prior to any cost sharing so that would be combined between PCP or mental health so you know two PCP visits one mental health all three PCP visits it's a combination and that's consistent with some of the non-standard plan design options that are available currently so again speaking to kind of that member experience and then ensuring there's not a lot of confusion with members we did align those with the non-standard plan options that are out there in order to offer that free cost sharing visits we did increase the copays once that's achieved to $40 on the PCP and off mental health visits and then in order to maintain a similar relationship between the PCP copays and specialists and urgent care and so on we have similar increases to the other levels in addition because that is a benefit to the member that increases the the AV we also needed to increase the generic pharmacy copay and preferred brand copays to accommodate those changes as well so there are several changes to the cost sharing under this plan design but we did want to present it because it does represent a benefit to the member for those that have office visits and so they you know could have some free coverage before paying any cost sharing for those office visits under this plan design given so many changes that are required this plan design does have a small estimated premium impact of about 0.3 percent the second option again has all of the same changes to the medical and pharmacy deductible and out-of-pocket maximums but does not have the free PCP office visits or the increases to the copays and the trade-off there is is really the estimated premium impact is pretty much offset by the changes to the increases in deductible and out-of-pocket maximums so taking a look at the silver high deductible plans again looking at the changes in prior years generally speaking the medical deductible and out-of-pocket maximums have been increased as we mentioned these plan designs have a some separate regulations a lower limitation annual limitation on cost sharing relative to the other plan designs as well as a minimum deductible that these plans must meet in order to be considered HDHPs so looking at the change from 2021 to 2022 we increased the deductible $100 in addition there is a embedded out-of-pocket maximum for single members within a family that has been tracking with the federal annual limitation on cost sharing and so that was increased to reflect that that federal regulation as well. So looking at the 2022 plan design this plan came in at a 72.3% AV under the new calculator again this plan design does require changes in order to meet those de minimis range requirements and again similar to the silver deductible plan had quite a significant increase in AV relative to last year due to the changes in the underlying data of the AV calculator so we're looking at a 1.6 percentage point increase in AV of the 2022 standard plan design simply based on the changes made to the calculator under the recommended plan option similar with prior years we have increased the deductible and out-of-pocket maximum the maximum for 2022 for HDHPs is $70.50 so this brings it to the limit for 2022 as I mentioned we don't know exactly what the limit will be for 2023 though generally that increases about $100 every year as a check for you all in addition on the HDHPs the pharmacy deductible and out-of-pocket maximum are tied to the minimum deductible for HDHPs released by the IRS so again we don't have that number finalized for 2023 but based on historical changes we do anticipate that it will increase to $14.50 for this year so the options that we're reflecting here do already incorporate that change as needed and again the embedded single out-of-pocket maximum has been increased to 9100 consistent with the federal limitation and consistent with the changes we've made to this plan design in prior years so the deductible increase is larger generally than what we've made in prior years for this plan and that's really a function of needing to make that larger increase to offset the changes in the federal calculator in order to make sure that this plan meets those de minimis range requirements so looking at the estimated premium impact of that recommended plan we're looking at about a 0.3% impact and looking at the alternative plan this one further increases the generic pharmacy and preferred brand co-pays relative to the 2022 plan design so as a slightly smaller estimated premium impact however for these plans all services must be subject to the deductible except for preventive services in order to meet those HDHP requirements so the increase in co-pays is really only goes into effect after the member has already reached their deductible so it has a fairly small impact on the the final AV and the estimated premium impact. All right moving on to the bronze plans we're in the the final metal level stretch. The bronze deductible plan again as I mentioned this this plan generally with the bronze plans we've needed to make larger incremental increases year over year to accommodate the changes in the federal calculator so relative to say gold and platinum you'll notice that these plan design changes have been larger in magnitude relative to the other metal levels because the AV calculator did not change last year we made only changes to the medical deductible pharmacy deductible and medical out-of-pocket maximum on this plan design and for this year this plan with the update to the underlying data the 2022 plan design actually had a reduction in AV based on the new calculator so this plan continues to be within the de minimis range and meet requirements however consistent with prior years we are looking at some small incremental changes and and some changes in order to help offset some of the premium impacts of maintaining the same plan design and balance the cost sharing and in premium discussion so in the recommended plan the only change would be to increase the medical out-of-pocket maximum from 8,700 to 9,100 that's consistent with the change in the federal limits for this year so going from the high end of the limit in 2022 to again that that high end of the limit in 2023 and this has a estimated premium impact of about 0.8%. The alternative plan would additionally increase the medical deductible $150 to $6,600 again this has a similar premium impact to the recommended plan option as you increase those deductibles there's fewer and fewer members that tend to hit the deductible and so it requires larger incremental changes to really move the needle on the premium impact there if you were to increase the deductible. This is the bronze deductible plan that is not subject to the pharmacy limit in Vermont regulation this plan was first introduced in 2018 so it's a little bit newer plan than the other standard plans that we've been looking at generally speaking the year-over-year changes have been to the medical deductible and out-of-pocket maximum and pretty consistently tracking with the federal limitations each year. The one exception is 2021 where we did increase the generic pharmacy copay as well so looking at the 2022 plan design this has an AV of 64.2% again similar to the other bronze plan this had actually a small reduction in AV based on the change in the calculator and it does continue to meet the AV requirements for these plans without changes however looking at the recommended and alternative plans similar to prior discussions you know looking at those small incremental changes this year so that larger changes are not necessarily required next year. So for this plan design the medical deductible and out-of-pocket maximum is suggested to increase to $9,000 however similar to what we were seeing on the silver deductible plan we have included the first three visits for PCP or mental health office visits at $0 and then would continue the the copay of $40 that that they've had in prior years. So with the increase to the deductible and out-of-pocket maximum again this does have a benefit to the member in the terms of the the three free office visits. Because of the three office visits this AV is a little bit higher than the 2022 plan design so those increase in deductible and out-of-pocket maximum doesn't fully offset that increase in AV due to that benefit to the member and has an estimated premium impact of 0.9%. The alternative plan that we are showing here has a further increase in medical deductible and out-of-pocket maximum to $9,100 has a much lower AV in terms of the federal calculator relative to the 2022 plan design or the other option that we're showing here but has a similar premium impact. So I want to pause here to show just kind of the impact of the difference in models and data that can influence the AV calculation of a plan. So you can see the the premium impact under the Wakeley model is significantly different than the difference in the federal AV and so as I mentioned the carriers will use their own model they'll come up with a their own estimate for what that impact is but again just kind of highlighting the trade-offs between premium and cost sharing. This is Dana I'd just like to jump in with one point on the previous plan that Brittany just reviewed the bronze deductible with the RX limit. We Wakeley found that if we had proposed the three PCP or mental health behavioral health visits on this plan it would have had such a large AV impact that it just didn't it didn't fit so that we decided against trying to squeeze it into this plan and and brought it into our proposal for the bronze deductible without the pharmacy limit. Yeah thanks Dana I meant to mention that and walked right past it. The difference with this bronze deductible plan with the pharmacy limit versus the other bronze plan is that currently the PCP and mental health office visits are subject to the deductible. So offering the three free visits is significantly more impactful on this plan than on the other bronze plan where those office visits are already pre-deductible but with a co-pay. I think when when we looked at it to put it into context adding those three free visits on this plan would have required I think approximately a $1,000 increase to the medical deductible in order to meet the AV requirements on this plan. So now on to the very last plan the bronze high deductible health plan. Very similar story here as far as the historical changes relative to the silver high deductible plan. Generally we've increased the medical deductible and out of pocket maximum each year and again increasing that embedded single out of pocket maximum to align with the federal limits year over year as well. For this plan the 2022 plan design is at a 62.9 percent AV. This is again a reduction from the AV that we had last year based on the changes to the calculator. However again we're you know recommending some some plan design changes in order to offset some of the premium impact and those those items limit future changes as well. So in the recommended plan design we have an increase to the deductible and out of pocket maximum of $100 on the deductible $50 on the out of pocket maximum as well as increasing the pharmacy deductible and out of pocket maximum again to align with the minimum deductible that we expect to hear from the IRS in the spring and then also increasing that single embedded out of pocket maximum up to the federal limit of $9100. The second alternative plan design is very similar to the first except that we left the out of pocket maximum at the same limit as 2022. Again fairly similar in terms of AV between these two plans the $50 limit didn't have a large impact but further trying to limit the estimated premium impact on a plan design that tends to have larger premium impacts. But again this plan is is limited in terms of the out of pocket maximum at a lower level than the federal limit at $9100. So that is $70.50 for 2022 generally increases $100 each year so we really don't have don't anticipate having a lot of room to increase the out of pocket maximum on this plan but have looked at increasing it a little bit for 2023. So again this slide is a rehash of the prior slide that kind of kicked off the standard plan design portion of the presentation. Just meant to be a summary of all of the changes that we've walked through which plans require Green Mountain Care Board approval explicitly but also a summary of the the plan design changes that that we're looking at for all plans. So as a reminder of a reminder we're seeking approval for the silver deductible plan design the bronze plan design without the pharmacy limit and the silver HTHP all other plan designs are below those thresholds. Though again we are providing that that summary here along with with the plans that do require approval. So that concludes the my part of the presentation. There's some additional information in the appendices of the presentation that Dina provided on the cost sharing reduction plan designs associated with the silver plan options that that we walked through. Those plan designs do not require approval and are tied to the standard silver plan. So kind of limited in terms of the decision points on those plans but we've provided them in the the appendices for you to review. In addition the appendices have those federal standard plan designs as well if you're interested in taking a look at those. Thank you Brittany. Dina is it okay for questions and comments? Yes. Okay I'll open it up to the board for questions or comments. Hi this is Robin. Thank you for your very thorough presentation Brittany. I would actually be interested in getting more background on the discussion related to the three visits with no cost sharing in terms of both Y3, Y the plans that you chose and not more consistently throughout the plan designs. Dina mentioned it in terms of the impact for the bronze deductible with Rx and of course the high deductible health plans have federal limitations but why not try to do something a little more consistent to make the messaging to the consumer a lot easier. I can start with that Brittany if I may. We definitely discussed the idea of introducing the behavioral health PCP visits at all metal levels and after a lot of discussion thought that the because the bronze excuse me the platinum and gold plans are richer with a lower you know significantly lower co-payment and deductible amounts to reach that that we thought the greater value would be in the silver and bronze plan so we excluded that from platinum and gold after considerable discussion and we to your other question we did start with discussion of two visits without without cost share after a lot of discussion for a couple of reasons landed on three it was first you know greater value to the you know to the enrollee we looked at the utilization of the free PCP behavioral health visits in non-standard plans and thought three might three was a better tipping point than two and also because of operational concerns where the non-standard plans are that offer that benefit are the the issuers have focused around three so there would be a greater operational lift if it had to be implemented with a number other than three so Brittany anything you would add there from the discussion yeah the only thing I would add is when we were looking at whether to offer two or three free PCP and mental health office visits the incremental AV impact of moving from two to three was was relatively small so in order you know being able to offer a higher benefit more benefit to the member for not a very significant cost in terms of AV impact and potential premium impact also I think influenced the decision of it is it possible to get the utilization information that you looked at in the non-standard plans I will take a look at that and yes so we can we're able to share great and then also I certainly understand like with that gold and platinum with platinum the the visits are I think $15 and $20 at gold but I'm curious to know if we wanted to have that same benefit at those levels if there are other AV other changes that would need to be made to to stay within the AV levels sorry I'm just I'm gonna scroll up so I can remember exactly where where those AVs are yeah and you can certainly get back to me you don't have to answer it today yeah yeah I think we would would need to yeah I think we would need to take a look at it generally speaking I think we have a little bit more room in terms of the high end of the AV range on platinum and gold so there there's potential that it could be added but we would have to take a look at it okay that'd be great thank you okay other questions or comments from the board I got a few um every year this feels like a brand new brand new corn maze you know that you've been out in the field planting corn and created a maze that is different from the one the year before it's so many moving parts so thank you for thank thank you for engaging in all this complexity um so I as I went through this year's presentation there were um you know a few areas and I think you mentioned them during your presentation here where stuff is not in final form yet you know I heard a quick list is the notice for benefit and payment parameters still in draft form the federal hthp minimum deductible mope limits are not yet released for 2023 the federal AVs uh calculator um is is based on summarized national data but in the end it's the carriers uh utilization and experience data that kind of drives the bus and I'm just wondering given these we're here we're being asked to approve um cost sharing increases that get baked in going forward to our rate review process when these plans come before us in rate review um you know how much volatility does the fact that we don't are there any of these pieces of information that we don't have that are final not final um more critical than others or is this just noise at the edge of the process yeah so one quick clarification the federal av calculator it is in draft form it's not finalized but that is the calculator that we have to use to determine compliance with the the metal level av de minimis ranges um so the carriers will use uh their own price their own models to determine the premium impact um but in order to determine compliance of the cost sharing and the plan designs themselves um we do have the draft version of that that calculator as far as the items that are not finalized and let me just follow up on that point so we're going to be making decisions based on this draft calculator but the final could be somewhat different but it's still this calculator that that counts in terms of the process so the yeah the final calculator uh I think it's very rare that there have been changes between the draft version of the calculator that these av amounts are based on um in the final version I can't necessarily name a time off the top of my head where that has specifically changed um so the I think there's not a lot of um worry that that may change although it's certainly possible and so that's what we want to to make aware um as far as the other items that are draft that could potentially change things um as a an example last year the draft notice of benefit and payment parameters suggested a federal limitation on cost sharing of 9100 up from 8550 and between the draft version and the final version the administration changed and they reduced that amount to 8700 um so we did have to come back to the board and present new plan designs that were compliant with that that change so there is the potential that some of these will impact the plan designs um but I think generally speaking the plan design changes that we've had to make in the past and Dana can correct me if I'm wrong but I think generally speaking the plan designs we've made after this point have been relatively small that's true I would also want to just underscore the point that um you know with our expert advice from Wakeley they they're very good at anticipating what the changes would be and some of the anticipated changes are already built into our proposed plan design so um that mitigates the need to return with corrected figures but um if there was as Brittany said if there were any changes required based on unexpected changes between now and the release of the final figures we will bring that back to the board well thank you for that um so I'm looking at some of these uh recommended changes as per cents as opposed to dollar amounts and uh so looking at the silver plan the increase in the medically deductible from 3400 to 4000 that's a 17.6 percent increase the increase in combined um out-of-pocket maximum from 8550 to 9100 is a 6.4 percent increase the um the amount associated with associated with the emergency room co-payment is 100% increase going from 250 to 500 dollars and so I kind of look at that um and uh there are some other increases you know that have just been um that are quite large that are just part of divas presentation and that aren't coming to us and then you get out to the estimated premium impact range and you know it's like two tenths of a percent um for the platinum three tenths of a percent for the silver um and then in the bronze you you get to eight tenths of percent nine tenths of a percent and 1.2 percent and I'm just wondering have you folks ever gone back and looked at um looked in the rear view mirror and said well this is what we told the board and now we've gone through a rate review etc etc and and and it's finalized um and we were right on the money or we were off because it you know for me it's just hard to look at these kind of percentage increases and knowing you know on top of thousands of dollars the base that are already there and kind of say yes to them I mean maybe I have to say yes but to say yes to them but then think about this entire process going forward and in rate review and these these these increases are already baked in when the carriers come to rate review and they're never discussed again and I'm just wondering you know just trying to get a sense of certitude that in saying yes to these that they're somehow statistically related to the estimated premium impact range that that relationship um is a tight one and one that we can you know rely on as assuming so much changes including the fact that the carriers in the end are the ones that that that are the the basis for the the premium increases that they present on board so I'm just wondering have you folks ever gone back and looked at your work against the reality as it actually unfolded and feel comfortable that what's being presented to us is is putting us on pretty solid ground? Yeah so unfortunately it's really difficult to tease out these benefit the specific benefit changes when it comes to the rate filings. As I mentioned what we're showing here is based on Wakeley's model the carriers will use their own model what we're really trying to provide is is another data point for your consideration but the carriers are ultimately going to use their own model's price and it could differ from what we're showing here. In addition because we're really just focused on those benefit design changes when we look at the actual premium filings there's a lot of other items that are baked into that so medical cost trends and you sort of changes in provider contracting induced utilization assumptions made by the carriers so there are a lot of other components that really feed into the the premium change and those rate filing pieces that make it really difficult for us to tease out this specific piece of it in order to do an apples to apples comparison to to what we're showing here. I would like to add to the on behalf of the whole stakeholder group you know there's a lot of discomfort around some of the magnitude of the cost share changes that are required to move that needle on the actuarial value so that if it was anything less than that we wouldn't have the impact that we would need to keep a particular plan compliant with with the AV in the new or upcoming benefit year so and then as Brittany said the the data point or the reference to anticipated premium impact is directional it's not you know it's it's helping provide an additional consideration for you know among other things we're doing you know making one choice with a benefit cost share change versus another and you know keeping that in mind what is likely to happen with premium understanding that it's still calculated by the by the issuers based on their utilization and data rather than this. I wonder if there's any I guess it's just our own discipline then that we have to keep in mind that when we get to rave review we've already approved these increases and some of them you know are de minimis in the big structure of stuff but when you are the the the I want to say patient but that's not what I'm looking for when you're the individual out there that's that the member in the plan and and that's your deductibles that are going up by 16 percent you feel it and I'm sure they feel that and I just got to keep that in mind that we're not starting with a blank slate when we're going to rave review we've already increased for those folks their co insurance their copayments. Another I have a couple more questions one is on it was on the three PCP visits and because the beginning you had a slide as to what was in our domain and I think the language is that the guardrail was $15 on copayments but this is a $35 decrease so it's outside that $15 range it goes from 35 down to nothing and so that's a $35 change and I'm wondering if if we should have a vote on that or or is maybe it's just the way it's written I don't understand it clearly but I thought that the or as I read it that the guardrail was $15 and change whether it's up or down and this one happens to be down and it's $35. I have not responded that there's if this is a just an alteration to the structure for those three visits but then when the copayment returns after those three visits are up there there's still a copayment that's very similar to the previous year we you know in the silver plan there would be I think it's a $5 increase in the cost share after three visits in the bronze that would stay the same so we're not eliminating cost share for all PCP mental health visits but for the first three hasn't added value I'll also add that those plans have other changes that require approval as well so those those plans need specific approval for for other changes yeah anyway and I think maybe my final question is the fact that this is will be the second year of these new federal subsidies expanded federal subsidies I think 22 was the first year how does how does that factor into your your your deliberations or your that the thinking of the working group about you know I mean because sometimes I worry that these these subsidies that really make healthcare affordable some people but that's also an area into which you know people who want to expand benefits etc might want to grow and so over time then the that affordability that's been achieved gets diminished and I'm just wondering if in your deliberations are people pretty aware that those subsidies are out there making making these plans more affordable and therefore they can afford to you do more well let's just clear most subsidies the expansion of those subsidies are not available for next year yet well I understand that I I guess I'm making the statehouse assumption in Congress that once you put something in place you can't take it away but you're absolutely right was it built back better and that bill is dead so the question is do they get together and put it someplace else and that's a whole another question for Dana as well because there's language in in our state legislature that would allow the date to be held out there as September 1st and in the past diva's always wanted information to input for the exchange product before that so just to piggyback on to your question and just to make it clear that nothing is set in stone at this point as far as emerged or unmerged market or anything yes and and our role too is to propose plans that are compliant with their actual real value so whether the subsidies continue or not were required to do that and by continuing with the quote unquote silver loading program that continues the cost sharing reduction program um for one which is you know we're entitled to do um so I think we just had to go forward with you know the AV review work that we've always done with this and and hope that the subsidies remain but it's it's the same requirement whether or not they continue so that I mean so I I think the combination of the answers is that yes those subsidies are in the background and assumed but the chair is absolutely right nothing and nothing is is baked in stone or baked in whatever it is baked in baked baked in certainty so all right thank you very much and thank you for your work on this is incredibly complex and don't don't don't ever give me a test on it because there's too many moving parts um but thank you Dana can you live with that proposed September 1st date unmerging or unmerging markets yes we think that's kind of the outer limit you know in terms of operational you know readiness after that but yeah we think the 911 date would be okay okay other questions or comments from the board this is Tom uh Tom Walsh following Tom Bell um thanks for thanks for all your work and um a lot of this is is new to me so I have a couple questions that um just helped me get my head around this a bit with the slides that you had could you bring those back up and go to slide 14 for me please here you go thank you so yeah I was I was trying to understand um this and it it's I think some of my questions are along the line of Tom Pease it seems that there are a lot of a lot of inputs into the model that right now um have uncertainty around them and that uncertainty around the components I don't have a good idea how much uncertainty is there is that a is that a 1% 2% or 5% swing either way with each of those variables can you help me understand that a little bit more yeah so the purpose of um the pricing model and what we're showing is the the estimated premium impact again we're really focusing solely on these benefit changes um so what we have is a model and and the av calculator works similarly but different methodology um but we've got it seems like the av calculator though pardon me the av calculator it's an estimate right now but you're fairly sure that it's going to be similar it's it's a draft version um so they submit the federal av calculator for public comment so there is potential that they could make changes to it but again pretty unlikely that that seems pretty solid then yeah but the the other model that you're talking about that seems to have a lot of components to it that seem each of those components can vary somewhat and I'm just trying to get a sense of how much variability yeah so the the other model that we're using it's it's wakely's pricing model but it's it's really meant to do uh benefit modeling so we take um our underlying proprietary data it's based on individual um and small group data nationally so kind of a similar population to the av calculator um and applies uh continuance tables and these cost sharing to determine the portion of benefits paid by the member versus the the carrier um and that's the av that that we're uh that we're showing it's the actual value um so the components that we're not accounting for in that I think are the ones that have more uncertainty um and that's really around you know what providers are contracting or what carriers are provided contracting with their providers um what their underlying data data looks like they'll use a different set of underlying data versus what we have so we're using the tools that are disposed I don't think that I wouldn't say that there's um necessarily uncertainty around it but I think there are different method all methodological approaches and different data that the carriers will use to do their actual determinations of the the av right and so I'm trying to get a sense of you've you've been clear on this slide and in other parts of the conversation about some uncertainty and then you've presented the tables to us and how sure can I be that those figures are going to stay pretty much where they are or they change a lot between now and great review yeah so I think this is uh similar to Tom's question before um we are fairly you know the the federal avs that use to determine the metal levels and the de minimis ranges are fairly set because we're required to use the federal av calculator um while in draft form unlikely to change so those federal avs are set um the weekly the the estimated premium impacts I would say are are not we we know that the carriers will will differ in terms of their impacts um from what we're showing here so what we're showing here is is really meant to again provide a data point of the trade-offs and potential conversation around you know a hundred dollar increase to the deductible versus this here's kind of direction directionality more than anything Dana had mentioned that earlier they're more directional estimates than a spot on estimate right I think that's can I just jump in on this point when you're finished with your thought Tom yeah um you can jump in anytime I interrupt it all the time at home this well sorry about that I would just want to make a note that um when we do rate review we do see impacts from benefit design changes my in my recollection the only uh benefit design changes that I would call significant in the past few years has been around a major change uh that was legislatively driven related to chiropractor and physical therapy visit copays so we do see the actual impacts from the carriers based on the state data so the differences wakely's data and the carriers data are not the same so the numbers will not be the same but personally I don't think we've seen that be a huge issue in rate review monetarily speaking thank you that's that's where I was trying to get to right and if we could um from past years right we're we're saying there's uncertainty now we we expect certain things and we can't really predict but as Tom was saying previously we could look back and see how the expectations matched with observed and what you're telling me is that there's not big changes not that I can recall other than the chiropractic and PT and I think we could do that but I think quite frankly that would be on us or our staff and actuarial support not on wakely because they don't have access they're not our actuary for rate review so they don't have that information so I think if we wanted to do that that would be something that we would ask our actuaries and rate review to do if we felt like it was worth the cost I appreciate add to the conversation is just to kind of emphasize you know even among the issuers they're going to have different estimates I just went back quickly to make sure it was still the case because I remember being the case a couple years ago where for the silver standard plan designs um one of the issuers has the deductible plan as being more expensive than the hdhp and the other one has the hdhp being more expensive than the deductible plan so they even in their pricing models have valued the impact of the the relative impact of those different plan designs so again it really is kind of what their experience is it could be their underlying populations um hopefully this is just kind of an incremental change to kind of how they've already set the premiums but based on their data they still may come up with different estimates so yeah to rodin's point we're we're definitely happy too if you do go through the process of collecting the information we can consider that in the future as we're putting together pricing estimates yeah it was just helpful to me to think about past performance and how what how well things line up right um and I think the other thing and this again follows very closely with with tom I think the percent change would be a good column to to have because in the lower the silver and and bronze plans um those are substantial percentage changes and to any of us managing our own budget a 15 percent change is meaningful to us and and I think that that would be helpful framing for when we're considering these changes so if possible I think that that'd be a nice addition that's all thank you thank you thank you tom is there other public comment other board comment or questions if not I'll open it up to public comment and I'll recognize Dale hack it first Dale so bear with me I'm going to describe a quick scenario the best I can um take it for what it's worth but I think it's a scenario that will play out I'm looking at this I'm looking at what I can afford to buy I've got two kids a little one one that's about six years old and I'm trying to find a plan I can afford to buy and I can I can just see myself getting by on that premium right there but uh I'm looking at the out of pocket max is no way I can afford that I can afford a couple doctor visits but boy if I have anything major come up it's just a debt that's all it is there's no way I can afford it um you only think I want to do I don't want to buy health insurance I think I can take the premium because I got a son that's got epilepsy I've got to be able to afford his medications I think I can do more by not buying the health insurance make sure that I can buy the medication and put food on the table a diet that serves epileptics and supposed to help prevent seizures and do these like my daycare I can more easily afford and that means I can work because I'm better off in terms of I know I've got daycare yeah this is a pretty good deal I can actually get more value by not buying health care except for the tragedy that might hit then if I actually buy it because once I buy it I've lost the money within the household and I still can't afford anything and a comment but Dale just to follow up on your comment you can't make a blatant statement like that because depending on what those incentives are at the end of the day um you might be much better off buying the product because you may get enough help so that it wouldn't be less expensive just to not insure so it's it's a tough one it depends on exactly what your income is that's why everybody really has to use the calculator and make their decisions but I don't personally I don't think I could ever recommend to somebody that it's their best option to not buy the insurance I think there is a window in there where it is true it doesn't I know what you're saying Kevin and I agree with you but when I'm on the other end as the dad or the mom I think that's going to be true there are some that are going to end up in that situation and it will be the reality it shouldn't be we we shouldn't allow it but it could be the truth well let's hope that there's some reason that occurs down in Washington and that the enhanced incentives are approved again for next year I agree um but that's why I said the way I did I just wanted to flag that as like boy this is really alarming to me um and that was my way of saying it okay thanks thanks Dale Walter carpenter thanks Kevin just a couple short more comments thanks to Tom for what he had said earlier about do these people ever consider the repercussions of their rate increases because I think that those who make these rate increases and do all these plans should actually have to live them and pay for them themselves to understand what it means for us to have to pay for them all the deductibles all the co-pays and the sheer vast complexity of trying to figure out these plans the next comment is that why in America do we have to make something simple so complex I mean I think a NASA moon launch is less complex than what we've heard today that is thank you Walter is there other public comment is there other public comment hearing none I wish to uh thank you Dana and Brittany and Addy and Julie and everyone um it's a complex subject and it's one that you do some more work on and uh we'll continue this conversation but thank you for the presentation today it was very helpful thank you thank you for your time and attention we'll be back next week thanks thanks it's like it's like Arnold Schwarzenegger I'll be back I'll be back is there any old business to come before the board is there any new business to come before the board is there a motion to adjourn there is second second it's it's been moved and seconded to adjourn all those in favor please signify by saying aye aye any opposed signify by saying nay thank you everyone and have a great rest of the day thank you