 Good afternoon. Seeing it's 1 o'clock, we'll call to order the green man care boards meeting of February 1st 2023. Today, we'll be hearing from Dana, who land from the agency of human services. Dana is the exchange project director, and we'll be discussing the 2024 standard qualified qualified health plan designs. And 1st, we'll take up the minutes from January 18th 2023. Is there any board discussion relating to the January 18th meeting minutes? Is there a motion to approve? Yeah, so moved. Second. All those in favor, please say aye. Aye. Aye. And the motion carries and the minutes are unanimously approved. And with that, I'll turn it over to Ms. Susan Barrett for the executive director's report. Thank you, Mr. Chair. Some scheduling announcements are scheduled for February for our regular board meetings at 1 p.m. on Wednesdays is posted on our website under board meetings. I also want to announce that on Monday, this coming Monday, February 6th. The board will be having a general advisory committee meeting with our general advisory committee and that starts at 2 p.m. and that's held virtually through teams on Monday. In addition, on February 15th, we'll be meeting with our primary care advisory group and that meeting starts at 5 p.m. Again, February 15th. It's a Wednesday. That also is virtual and for all of those meetings, there is a physical location if folks cannot access the meeting through teams. In addition, I know as a chair foster, we'll be hearing from Dana Houlihan today and his team on the 2020 for qualified health plan designs and we opened a public comment period on January 31st. That public comment period will run through February 7th and the board has a potential vote on these plans for February 8th. So, if you could get your comments in to us, so they could be considered ahead of the vote, that would be helpful. And last, but certainly not least, we have an ongoing public comment period regarding a potential next model with the centers for Medicare and Medicaid innovations and CMS. We are accepting any comments on that next model and we will share those with the administration and our AHS as they are leading the negotiations and the all pair model. And with that, I'll turn it back to you, Mr. Chair. Thank you very much. I'll just turn it over directly to Mr. Houlihan and Dana, if you could please introduce your team and take it away. Thank you. Yes, thank you. Let me just, okay, we're sorted out now. Good afternoon, everyone. Dana Houlihan from the Department of Homeland Health Access. I'm the plan management director. And I'm joined by Addie Stermelo, who is our deputy commissioner at Diva, and by Darren Johnson, Julie Pepper, and Alex Taraki from Wakeley Consulting, our editorial partners for this process. So we'll start with comments from Addie. Take it away. Thank you, Dana. Hi, everyone. As Dana said, my name is Addie Stermelo. I am a deputy commissioner at the Department of Vermont Health Access. I traditionally come with Dana to provide some kind of opening remarks in some context ahead of the plan design presentation. In my capacity at Diva, I oversee eligibility and enrollment. And as you may know, at Diva, we have an integrated marketplace that performs eligibility and enrollment for Medicaid, in addition to qualified health plans. So I wanted to offer a few comments about other things that are kind of going on in the marketplace right now that you may have read about or otherwise heard about, just to provide some context, even though they are not directly related to the plan design presentation. The first relates to Medicaid renewals. So since 2020, Diva and all Medicaid agencies across the country have been keeping people on Medicaid pursuant to a federal policy during the pandemic. So Vermonters have remained on Medicaid, even if they no longer qualify. This protection called continuous coverage was established by Congress in conjunction with increased Medicaid funding during the public health emergency. And this measure has been in place to help ensure as many people as possible keep their health insurance and access to health care during the pandemic. So during the last three years, our enrollment has grown because of this. It's grown by over 20 percent. And our marketplace enrollment, which you will see when we provide that data, I think in our next presentation, has actually been down because of that, because we haven't seen that usual churn between the programs. About a month ago, Congress passed a bill that ends that continuous coverage requirement for Medicaid. So starting this April, Medicaid renewals will begin again. Renewals are the term that we use for the federally required process to recheck eligibility for Medicaid every year. This is what was suspended during the continuous coverage period. And it will be starting up again this spring. I think one thing we want to make clear to everyone is that it's not a change with respect to who can be on Medicaid. It's just returning to normal processes. But it is going to be a change generally because there are people who have been on Medicaid for three years without having to engage in this process. So we've been we've been planning on it for quite a period of time now. And I think a few key points that we wanted to share with you all is that this will happen gradually over a period of a year or more. Members will get special communications when their renewal month is coming up. And so we're taking some special steps around communications, making sure we have updated contact information, special messaging, streamlining the renewal process itself, maximizing use of data sources and trying to minimize needed outreach to Vermonters on Medicaid. And then also just really trying to facilitate transition to other coverage to the extent that people find out that they're no longer Medicaid eligible through this process. So that brings me to my second topic, which is the marketplace subsidies. Since we were last before you there have been some major improvements related to the subsidy availability in the marketplace. First, the federal government fixed what is known as the family glitch, so improving access to subsidies for families who have an offer of employer-sponsored coverage. Second, Congress passed the Inflation Reduction Act, extending the expanded premium subsidies that were created by the American Rescue Plan Act in 2021 all the way through 2025. So that was a big relief last summer, not only for purposes of open enrollment, but also in terms of this prospect of returning to Medicaid renewals and the prospect of having some people coming off of Medicaid and into the marketplace want to make very clear that if someone is no longer eligible they will have for Medicaid, they will have that opportunity to enroll in the marketplace and get help paying for it thanks to these federal subsidies. We will, I think there was a question about this, we will have a special enrollment period for anyone coming off of Medicaid so there's not going to be any kind of policy barrier to marketplace enrollments during this restart process. The last topic I wanted to bring up again not directly related to the plan design but just for context is that there is a proposal in the governor's budget this year to eliminate the Vermont Cost Sharing Reduction Program in 2024. So this is what we call VCSR. It's a state funded program designed to reduce out-of-pocket costs for eligible qualified health plan enrollees. It was designed as a wrap for the federal cost sharing subsidies for those with household incomes 200 to 300 percent of the federal poverty level. I'll just briefly say I think the thought behind this proposal is that given the way Vermont's kind of consumption of the federal subsidies has evolved since its inception the program isn't filling kind of as critical a role with respect to affordability that it was intended to and may not be the best use of state dollars. But this is just a proposal and it, you know, I think there's a long way to go before we know if that's actually going to kind of come to be for 2024. It wouldn't impact plan design but it would impact kind of the rest of the QHP certification process. So the QHP stakeholder group, you know, discussed this and decided to kind of proceed with filing the forms as if VCSR will remain in place. And then if the proposal does pass the idea would be to pull back the forms that are specific to those the VCSR tier 77 silver 77 tier. But that gets a little bit technical. You'll see in some of the slides that that tier is reflected. But again, the thought is to kind of do the form filing based on current law and kind of and go from there depending on how the session goes. So I think that covers my overview. It's going to be a busy season, busy year in the marketplace, and we appreciate your partnership. I'm happy to take any general questions, but I know we also have a lot to present that is specific to plan design. So thank you for your time. Thank you, Adi. I have one quick question that the number of people who've been enrolled in the expanded access that are that will be unenrolled, did you have a number for that? I missed it. No, we're not going to give a projection around the number of people who might lose Medicaid. I mean, what I can say is that our current enrollment is around 200,000. We have to renew all 200,000. And whether someone remains eligible will depend on what's going on with them, their personal circumstances and their participation in the renewal process. I can say that we're going to in the renewal process prioritize the subset of the Medicaid population that's already told us they're no longer eligible. So they've reported additional income or change in job so that we can facilitate that transition to the marketplace as early in the process as possible. So just we do have those kind of subpopulations that we can talk through, but there's no actual projection for the number of closures. Okay. Okay. Thanks. I have one quick question. Adi, when you come in with the number, the enrollment figures next week, will it be clear how many folks are in the Silver 77 or from the current enrollment? Dana, do we get that granular in the enrollment tables? No, generally it's aggregated, but there's no reason we couldn't pull out that number. Sure. That would be helpful. Thank you. Just to understand the impact, potential impact, I should say. I'm making a note. Thanks, Dana. Okay. Shall we begin? Can everyone see the screen? The presentation all set? Looks good, Dana. Okay. Thanks. So I'll just begin with a few slides to kind of frame up our discussion and provide some context about our process to build this presentation. Then I will turn it over to Wigley Consulting to make art to present our proposals and first to describe the federal guidance changes within the 2024 payment notice. These change every year in addition to a something called the actuarial value calculator used to guide this process as well. So those are the important objectives for today and then between this meeting and next week, we will gather comments, questions, and further discussion in preparation hopefully for the vote next week. Thank you. As a reminder, just for context, there are 14 standard and 14 non-standard. That's seven each category from both issuers. We are focusing on this section right here, not the non-standard plans, which are just not part of this process. So we're focusing on it's one platinum, one gold, two silver, and three bronze for each medical issuer. We're worried about our stakeholder process and composition. Was there a question? Let me speak over anyone. We have a stakeholder group that begins meeting in mid to late November and we meet weekly, finished our discussions and decisions last week. In fact, in preparation for today, we have representatives from all of the issuers. We have two representatives from the healthcare advocate's office, important for the consumer perspective in particular. And then of course we have representatives from DFR and the Green Mountain Care Board as our other regulators in Vermont for the exchange. So if we have active discussion at each meeting, weekly consulting provides us with planned modeling. We look back at the changes that have been done in previous years, factor in the changes for the upcoming year and what would need to change in terms of the benefits to remain compliant or to make our best proposal for the following year. We come to consensus when we can, not always possible, but this year I believe for every one of our decisions after a robust discussion we did have consensus, which is good. I won't read these, but these are principles that are in our minds as we go through our process to make the best decisions that we can within the options that we have for changes and to make, as I said, the best possible set of decisions for standard plans for Vermonters. Another word on affordability here, we thought it was important to add specific to the plans at the silver level. The silver plan, both issuers have four silver plans, so that's eight total. The silver plan, the second lowest cost silver plan is used to calculate APTC, so it's a significant factor for affordability, of course. Generally speaking, the higher the AV, the higher the premium it will be. So we just wanted to add a statement that the DEVA, the state, favors and supports the concept of trying to maximize the AV at the silver level in an effort to maximize subsidy for Vermonters who are eligible. And there'll be more, this last point here about the AV ranges. There'll be more detail on this later in the presentation, but in the last couple of years, the federal guidelines have impressed the range for acceptable silver plan AVs. So it's narrowed on the upper side. There's typically B, for example, 70% plus or minus 2%. For silver plans, there's no longer an ability to go below 70%. It's 70 plus two. There'll be more detail to follow in that. More about our process. As you'll see with each one of the plans, we are required to make changes to bring a plan into compliance if the AV using the new calculator would be out of range. In some instances, even if we are within range, our approach is to do smaller incremental increases year over year rather than holding back and then being required to make a more drastic change in future years, which could be difficult for consumers. So we're trying to be mindful of overall cost for a plan and affordability in terms of the out-of-pocket components. And then, of course, we always try to avoid any kind of a benefit design that would be difficult for consumers to understand and use. I wanted to make the note too that silver loading continues in 2024. This is the mechanism to fund the CSR program. And this is done by most exchanges in the country. So that will be continuing as usual for 2024. And then lastly, I wanted to just pull out a few things important in the timeline. I did provide a comprehensive 2024 timeline document for the board. But just some of the highlights are that we are in the first step mentioned here before the board for presentation of the design adjustments for 2024. In March, the issuers will submit their form documents, the summaries of benefits and coverage and contracts to DFR for review, which will conclude in June. We expect to have the final parameters from CMS and IRS limits in the spring of 2023. That's typically when it's been received before. In May of 2023, the issuers will make their rate proposals. That begins a process, as you're well aware, with the board through rate review and hearings and decisions in August. Also, in August, following final rates or receipts is the Diva commissioner formally completes certification of the plans to be offered on the exchange. And then from there, it's all many, many steps to prepare for open enrollment, which will be November 1st of 2023 to January 15th. So from here, I will turn it over to Darren. Can you see my screen? Seeing some, that's not perfect. Yeah, so my name is Darren Johnson. I'm a consulting actuary with Wickley Consulting Group. We help with the actuarial portion of the standard plan analysis. And I'll just kind of take you through the work the stakeholder group has been doing this winter. So quick outline of what we'll be covering. We'll spend some time going over kind of the proposed regulation changes for 2024, coming from the federal level, what changes we've seen in the federal AB calculator that will impact the ranges we can have for the standard plan designs, and then the stakeholder group recommendations for each plan design changed by metal level. So we have the 2024 draft notice of benefit and payment parameters. As Dana noted, we'll have a final one coming out in the next couple of months. We use the draft one for this portion. We also have the annual limitation on cash sharing that was released in a separate guidance letter that is finalized, setting the limit for individual maximum amount of pockets at $9,450 for 2024, an increase of $250 from 2023. Separately, we do not yet have the federal HDHP minimum deductible and moop limits. We have the ones from 2023 because of kind of past experience. We don't really anticipate a 2024 deductible increase. In addition, because the the moop for HDHPs was increased by so much last year, we don't necessarily anticipate a 2024 moop increase either. We'll see what happens when that is released. For the proposed plan designs, we assumed that the deductible would remain at the same level. If that limit is adjusted, we might need to tweak the pharmacy deductible for some of the HDHPs. There are other changes not listed here. We thought these were the most material ones to the plan designs. So we also have the 2024 draft actuarial value calculator. Again, this one is still in draft status as well. The final one should be released at some point in the next couple months. Typically, we do not see changes between draft and final, but you never know when you might get a curveball. This model is used to determine the actuarial value of the plan for the purpose of bucketing a plan into those different metal levels. I hope it includes inputs for a lot of different plan design features, your high-level deductibles out of pocket maxims, as well as copays and coinsurance for a number of different service categories. There are plan design features that are not supported by the AV calculator. If these features are substantial, we can either try to modify the inputs to account for that or separately adjust for those plan design features. We'll talk about this more in a little bit. Note that again, the AV that comes from this calculator is not the same as the pricing AV that carriers will calculate as an input into the premium determination process. This calculator is based on summarized national data. It's not Vermont-specific. You have limits to how much you can calibrate the data, and then there's those plan design features that are not necessarily supported that could differ, as well as potentially mythological differences between the federal AV calculator and issuers individual AV calculators. So again, just draft format. There could still be changes, but what were the changes from the 2023 final to the 2024 draft? They stuck with the same data. It's 2018 individual and small group data, again, national data. They're trending it from 2018 to 2024. To trend from 23 to 24, they used a 5.4% medical and 8.2% pharmacy. You can kind of see in the table down below what that means for the allowed PMPMs at the different metal levels. There were some changes to the AV calculator logic this year. That doesn't always happen, but these ones are actually somewhat noticeable. So that first one, especially the copays, no longer accrue towards the deductible. The AV calculator in the past, it had a bit of a deficiency where it would accrue copays on primary care or generic drugs or whatever towards the deductible, which from our experience is not how issuers actually adjudicate those benefits. So by removing that change, that drove actuarial values down a plan that doesn't accrue copays towards the deductible is less rich than a plan that does, which helped this year by reducing the magnitude of changes needed. The increases in cost sharing needed to ensure that planes were still in compliance with those AV ranges. So this is a one-time thing. It's probably not going to change in future years, but definitely helped this year with reducing the magnitude of cost sharing increases needed to stay within those ranges. There was another adjustment for the calculation for planes likely to meet their maximum out-of-pocket for the deductible. That's pretty rare. It's a much more minor adjustment, but just wanted to note it. So this slide has a lot of words on it, but is definitely an important slide. So as we go into the plan designs, we're going to show an estimated premium impact in addition to the change in the draft and the actuarial value, federal actuarial values from last year to this year. We're going to show this estimated premium impact as well. That's meant to show that there is a bit of a trade-off between premium increases and cost sharing increases. If you make a plan richer, the premium gets higher. If you make a plan less rich, the premium gets lower. This is based on a Wakeley model that is based on national data. We calibrate it some to Vermont specific experience, but obviously there's a limit to how much we can do there. There's things we don't adjust for that the issuers certainly will. This premium change does not take into account a number of different variables that again the issuers will when they're putting together their actual pricing for this coming year. It's really just meant to kind of illustrate the impact to the actuarial value from plan design changes and from sort of trend year over year. Yes, so given this new actuarial value calculator, what's kind of the landscape of changes that we're looking at? Changes are required for the bronze deductible without drug limit plan and the silver HDHP plan. The plan designs from the previous year are no longer compliant. They're not falling into the required ranges by maybe calculator. For all the other plans, even if changes are not required, we generally still kind of lean toward changes to avoid the AB increase either being passed on as premium increases or requiring larger changes in future years. There were also some changes required on the silver CSR plan designs that we don't cover as much in this presentation. That information is available in the appendix if you want to look at it. The acceptable AV ranges below, we'll go into that on the next slide, reflect both the changes in the draft MPPP and then there's a number of kind of the side adjustments we have to make to the calculator because it does not include the full range of possible plan design features. So HDHPs in Vermont waived the deductible on preventive prescription drugs. The issuers kind of looked into that assumption again this year and confirmed that adding about a 0.5% cushion was kind of a way to model that. In addition, out-of-pocket expenses are limited for insulin. We did some modeling on that last year. It seemed like it only really had an impact on bronze plans. We're kind of added a little extra cushion on the high range of the plans. And then lastly, last year, all non-HDHP plans except bronze without drug limit had three free mental health and substance abuse visits as well as three PCP visits. The AB calculator does not support free mental health and substance abuse visits in its modeling. So we added this small multiplicative factor where we get a final AV and multiply it by 1.001 and then that's our final final AV and that's what we use to check compliance. So what does this all look like? Just to take an example, a silver plan last year or 71.7 this year is 70.9. So it actually decreased substantially. That is not normal. That is due to the change in methodology with how they're handling co-pays. The acceptable range is 70 to 72. That kind of goes back to Dana. It used to be 68 to 72. As he said, they kind of lopped off the bottom. So now it's 70 to 72. The bronze HDHP plan last year was a 62.9. This year it increased slightly to 63.1. The acceptable range to that is 58 to 64.4. The federal requirement would be up to 65, but we add that cushion the 0.5 percent for the preventive drugs and then the 0.1 percent for the insulin limitation. So you can kind of see how all those ranges get adjusted based on those requirements. And then as noted, the bronze without drug limit and the silver HDHP were ones that are now outside of the top end of the range using the plan design from last year. There are, after we make changes to these plan designs to kind of get within those ranges or balance premium impacts, there are some changes that require formal approval from the Green Mountain Care Board. This year there was only one kind of primary plan design that we chose that required that it gets outside of these ranges. We'll get to that in a moment. One other change that came this year was updating Vermont's EHB benchmark plan to include hearing aid coverage, both an annual exam and then one hearing aid per year every three years. The stakeholder group decided that the annual exam will be covered the same as specialist office visits, and then hearing aids will be covered the same as durable medical equipment, which is typically deductible in coinsurance. This has a minimal impact on plan design, actual value. We don't think any additional calculations are required. So before I hop into kind of the meat of the presentation, were there any questions from that long intro? Perfect. So this is just kind of a summary slide of all the changes we've made, just kind of to refer back to. As noted, highlighted in green is the one plan where we have a kind of a primary recommendation that is exceeds the limits for Green Mountain Care Board approval, requiring Green Mountain Care Board approval, and we'll touch on that more when we get to that plan. So starting off with platinum deductible. So on this slide, we're kind of showing the history over time of how this plan's cost sharing has changed. As you can see, generally, we're kind of trading off between loop changes, deductible changes, some years have both. Last year, we brought in the three free PCP visits and mental health and substance abuse visits. So this slide, we're showing the 2023 plan design, the kind of preferred option the stakeholder group decided on in our meetings, and then kind of a backup option that we wanted to also present. So here, we recommend it minor changes to the medical deductible, a $25 increase. We recommend it keeping the medical out-of-pocket max the same and a minor increase to the pharmacy out-of-pocket max to kind of bring it up to that HGHP limit, just kind of as a general place that we're taking things. This should have a pretty small impact. On ABC, it just decreases slightly from 90.2% to 90.1% compliance with the AB calculator is not really an issue here. We're pretty far from that 92% target. And the premium impact is pretty minor. We see a slight premium impact increase. If that seems confusing that we're reduced, there are reducing benefits and seeing an increase. What we're also modeling here is the impact of kind of leveraging. So we're modeling claim costs increase 23 to 24, which makes a given deductible level a little richer. So even if we kept the plan design the same, there would be a 0.4% increase in premium. So we're just cutting that back just a little bit. And that's kind of the recommended option there. So as mentioned, increasing the cost sharing, even though the plan design is within the AB ranges, we're recommending minor changes just to limit the impact on premium a little bit, you know, help avoid larger changes down the line and increase the pharmacy loop just to be consistent with the HGHP pharmacy loops onto the gold deductible plan. Again, just kind of showing the changes in cost sharing over time. I do want to note this plan has had deductible increases for the last four years, including a couple of years where there have been $200 deductible increases that definitely played into our decisions with this plan. So with this one, our preferred option was leaving the deductible alone, kind of giving consumers a break on the deductible and the medical out-of-pocket tax this year, increasing that pharmacy loop again to that 1,500 level. You'll be seeing that a lot. And then kind of achieving the reduction goals by focusing on co-pay increases instead. So you can see we kind of added $5 to a suite of co-pays, $3 to a pharmacy generic co-pay, allowing us to bring the 2024 ABC down a decent amount and limit the premium impact as well. You know, again, this plan is also under the target, even with the 2023 plan design, but if it's an 81.9% this year, next year, you're probably going to see, you know, a 1% increase or more in ABC. We just kind of avoided that this year because of that methodological change. So we think, you know, change of this magnitude is going to do a lot to prevent needing, you know, kind of the dramatic changes we've had in the past by spreading things out a little more this year. And then the backup option was just if we wanted to kind of get even more breathing room or cut premium impact even more, adding in a change to the medical out-of-pocket max and then adding in an ER co-pay increase as well. So as mentioned, we're trying to kind of cut those deductible increases after multiple years of increasing those limit premium impact. We're keeping the three free visits on PCP and mental health and substance abuse and then increasing that pharmacy moop. On to the silver deductible plan. Again, we're showing the year-over-year changes. This plan has deductible increases pretty much every year, aside from 2021. And again, brought in those three free visits last year. With this one, the 2023 plan design again is actually compliant with the 2024 calculator. This one again benefited a lot from that co-pay methodological change because a lot of services were covered with co-pays on this plan design. So the preferred option that the stakeholder group came up with was just kind of minor out-of-pocket max increases. Again, leave the deductible alone for a year. Just gain a little extra space next year against the AB calculator limit premium impact a little bit. And then we had a backup option where we just kind of really give consumers a break for a year, only increase the pharmacy boop, and then next year it might get a little tighter depending on the changes to the AB calculator. Next up, we've got the silver HDHP plan. So apologies for the giant slide here. It gets a little bit of a mouthful to describe the aggregate deductible structure. But this plan, again, has seen kind of deductible increases year over year, including a pretty substantial one last year. And then most years, moop increases as well. So on this one kind of similar to the gold plan, the stakeholder group recommendation was to again give consumers a break on those deductible and moop increases and instead focus on the co-insurance. So increasing co-insurance kind of across the board by 5%, as a way to get under the target without really hitting the deductible and boop hard. This plan is one that the target is that 71.5% because of the preventive pharmacy cushion we have to add to make sure we're in compliance since it is an HDHP. So the 2023 plan was at 72.3, so a pretty decent amount over that target. So increasing the co-insurance brought it down to a 71.3. So we're even then just not under the target by a whole lot. We did have a backup option if the co-insurance increases were not the direction we wanted to go where we use deductible and moop increases instead to get just under that target. But that requires a $200 deductible increase and a $450 increase to be out of pocket max. And then we'd want to know if something does happen to that HDHP minimal deductible when we get that released, we would have to adjust the pharmacy deductible and out of pocket max. I would not expect that to have a huge change on the final values. So again, yeah, similarly to the gold plan, we're just trying to kind of cut the trend of those large deductible and moop increases and switch things up a little bit while still limiting premium impact and getting into compliance. On to the bronze deductible plan. So not an HDHP, just the bronze deductible plan that has the pharmacy limit. So again, we're kind of showing the changes year over year. This one of note that drug deductible began being waived for generic scripts as well as preventive in 2021. And then last year, we just had a change to the out of pocket max and avoided deductible increases. So this year again, with these bronze plans, the target is so wide with that expanded bronze range from 58 to 65% that compliance with the AB calculator is not really an issue with these plans. It's more a question of trying to limit the premium impact because we generally expect that the consumers purchasing these bronze plans are going to be a little more cost sensitive. So again, with these, it's more about the premium impact than the AB calculator. As we can see our target is 64.9%. We have that 0.1% for that insulin cost sharing limitation and our last year's plan is at a 63.3%. So we're obviously way under the target. It's just more a question of the premium impact. So in this case, the stakeholders were kind of thinking, leave the deductibles where they are. This plan has generally, the MOOP has generally followed the maximum MOOP as it has changed year over year. Sometimes it's been a little lower, but a lot of the times it's been at the level of the maximum MOOP. So the primary recommendation was to continue with that, bring the MOOP up to that 94.50. Again, bring that pharmacy MOOP up to the 1500. That brings the premium impact just from plan design changes at right about a 1.1%. We did model just to see if we increased the pharmacy copay to $20, which it was in the past before 2021, brought it back up to that $20 amount, what impact that would have. And we didn't see a huge impact to premiums from that, just a little more than 0.1%, but wanted to include that as another option if we felt that premium impact was on the high end. Then on to the bronze deductible plan without the pharmacy limit. So this plan is just a pretty straightforward deductible equals out-of-pocket max plan with some free PCP and mental health visits starting last year and a selection of copays. So this is the one where we do kind of hit that green mountain care board required limits. Again, this is a plan that has typically had deductible and MOOPs pretty much at the maximum for the given year, just $100 less last year. And this was the other one where the target is 64.9%. Last year's plan design was at a 65.5%. So again, we're pretty far over the compliance threshold. So the preferred recommendation here was bring it up to the 9,400. That gets us kind of under the limit and gets a premium impact of less than 1%. And then we had a backup option of just going all the way up to the federal limit, the 9,450, which gets a little more breathing room for next year and lowers the premium impact just a bit. Because yeah, I think the 64.8 is like a 64.89. It's kind of right at the limit. So next year, this plan will probably be kind of right at the limit of compliance again. And then lastly, sorry, else is freezing. There we go. Lastly, there are Brown's HDHP. So again, just kind of showing the changes over time. It's just been at the 50% co-insurance is the maximum co-insurance you can charge. So we've stayed pretty much everything stayed kind of constant on that end, just deductible and loop increases year over year. And then the direct deductible is only waived for wellness scripts. So the recommendation this year, I apologize. It looks like I did not include the target on this slide for Brown's HDHP. It would be 64.4%, I believe. Again, we're at a 63.1. We're way below the target. It's just a question of premium impact. In this plan, we were showing a pretty substantial premium impact. Again, that's based on a wakely model. It's not calibrated fully to Vermont expectations. So that caveat applied. But we still, the stakeholder group still kind of felt that this plan has had pretty substantial deductible changes over time, kind of every year consumers have been getting hit with those increases. So the primary recommendation was to limit the deductible increase, just increase the pharmacy out-of-pocket max a little bit and have that premium impact maybe a little bit on the higher end, but reduce the cost sharing. A backup option was to increase the deductible as well. With this plan, it seems like the out-of-pocket max is more what changes the premium impact as opposed to the deductible. When you have 50% co-insurance, once you hit your deductible, you're still paying a pretty decent amount of cost sharing. It's really once you hit your out-of-pocket max that you're realizing higher savings. So there wasn't a huge change on premium impact from also increasing the deductible, but wanted to include the modeling for that option as well. And then again, since this is an HCHP, if that minimum deductible changes, we will have to adjust the modeling slightly for that. So again, just back to the total summary of recommended changes across the plan designs with the Browns Without Pharmacy Limit Plan being the one that kind of exceeded those green mountain care board thresholds. Any questions from that? I know that was a lot of dense x-rayal terminology and modeling, so thank you for sticking along. And then yeah, I know we include a number of appendices with some more detailed modeling, including the CSR plan designs and the silver-on-and-off exchange differences as well as the proposed federal standard plan designs. If you wanted to look through those. Awesome, thank you for your time. Thank you. Owen, are you on? I just want to make sure there wasn't an internet failure there. Okay, good, great. Come on, yeah. Dana, do you guys have more or are you guys complete on your end? That was our intended presentation for today. I expect that we would return next week with other information on enrollment and responses. Any other questions that may be raised between now and then? Okay, great. So I'll turn it, I'll open it up for any board questions or comments now and we're not going to have a vote this week, but I'll open up for board questions or comments. I do not have any questions or comments. Dana already anticipated my annual question about getting enrollment information. I don't have any either. Thank you, Owen. Thank you, Dana, and team for the presentation. Okay, I'll open it up. One question. I'm sorry. Go ahead, Dave. The one question I have is, and sorry to both of you, because I'm very new to this topic in this level of detail, but do we evaluate whether or not these, I mean, I know these plans are defined by federal guidelines, but do we evaluate whether or not we would consider these under insurance, in particular the bronze plans? Well, I guess I would just respond that in the framework of the Affordable Care Act and the bronze level that these do meet all of the you know, required coverages and so forth and the actuarial value, meaning the portion that the insurance companies pay versus the enrollee, but the out-of-pocket costs are substantial, especially in the lower, less rich metal levels. There's no question. A little bit of history might be helpful, which is originally when the Vermont, when Vermont was designing the exchange, the state actually tried to get out of offering bronze plans because there is such a high cost-sharing burden, but that was not allowable under the federal provisions. I just look at those cost-sharing percentages and think about, you know, I'm sorry to like burden everybody with like another thought from the emergency department, but like a patient who comes to the ED who's, you know, fairly healthy person says, okay, I'll get the bronze plan and then ends up with, you know, right lower quadrant abdominal pain, gets labs, a CT and they've got appendicitis and, you know, whether or not they go to surgery or not, like that adds up a lot and at 50% co-pay, you know, you're going to run right up to those out-of-pocket maxims, which is a lot of money and an unexpected cost. So, you know, I understand why we have it and it's just daunting to think about that impact on someone's financial well-being. David is. And one thing, you know, it might be obvious to everybody, but one thing that I remind myself of with each of these presentations, it's easy to get confused. Like max out-of-pocket doesn't include what you pay towards your premium, which comes out of your pocket, right? But it's premium and then the additional things. And your co-pay may not work towards your deductible. So, there are different streams that can continue to add up in very daunting ways. And I think it's important to just keep, be mindful that we be mindful of that. That's a good point. I just want to remind folks that the design of our plan comparison tool is to take those factors into account. It's the combination of premium and out-of-pocket costs and the higher the premium, the lower the out-of-pocket costs. But I think it really depends on a person's situation and expected utilization and all of these factors that are hard to have a perfect crystal ball. But there's definitely trade-offs there. No question. I appreciate the tool a lot. It's nice to be able to create different scenarios and try to think through them. I guess the other thing that, and I don't know if this is an appropriate question for this forum, but as we go through this Medicaid redetermination, people may be leaving Medicaid as an insurance and moving to something like a subsidized silver plan or maybe a bronze plan and the out-of-pocket costs could be substantially higher for individuals the way I see this. I don't think we have any modeling on that, but it sounds like this could be pretty impactful for a good number of homeowners. It would be nice to know more about what that number is about how many we expect to be coming off. I think it's also telling that with them coming off and coming off and having gone on, according to some theories about hospital finance, the amount and number of the amount of enrollees and the amount reimbursed for enrollees should affect commercial prices in predictable ways. We have not seen that in the state, according to the data, an outdated theory that's continued to be prevalent in our state. Thanks for the presentation. Okay. Unless there's any other board questions or comment at this time, I'll turn it over to the healthcare advocate. Sorry. Oh, sorry. Sorry. Just one more thing. I was holding till the end, but go now. There's a statement often in this presentation and others that we have about insurance that gradual increases are needed to avoid larger increases later. And that has such a commonsensical ring to it. It makes you almost don't want to question it. But I question it. It seems like every year we can say, well, we need to do this increase because it will prevent bigger increases later. But I don't know if it's ever prevented a big increase later because we've had big, big increases later, even after the little ones. So I question that statement. That's it. Thanks, Owen. Of course. Eric, I think I believe I heard your voice. If you're ready, please go ahead. So we appreciate the collaborative process and support the board approving these. I will note, this is a decision space that's substantially constrained by federal AV requirements. Dr. Merman, I think you raised an interesting point about bronze. I will note that it exists at many metal levels. I mean, I have ESI, a gold small group plan. I think my deductible, which we came within maybe $200 of hitting last year, is close to a grand. And I mean, I would consider myself a professional who is well above the median income. And that's like two months salary. I mean, it was substantial decisions had to be made for our budget. And it's very troubling to imagine what a household who does not have the means, which is a vast majority of Vermonters faces. And that was a difficulty that we had on a gold plan. So I can't even imagine. I honestly cannot even imagine what it's like to be on a bronze plan and to be making the median income. Thank you. Thank you for that comment very much, Eric. And it's true. When you do the math and then compare it even on anyone, any of our family incomes, you can see the challenges that it presents. And it is difficult to conceive of how those numbers work at various income levels for families. But thank you for sharing that comment. And I'll open it up to the public for public comment at this time. If you can use your raise your hand function, I'll call on folks. Okay, it looks like no public comment today. And with that, I'll thank you, Dana, very much for your presentation today. And we'll see you again soon. Thank you. Thank you all for your time. Appreciate it very much. Thank you. And with that, is there any new business to come before the board? Any old business? And is there a motion to adjourn? So moved. Second. All those in favor, please say aye. Aye. Aye. Aye. The motion carries and we are adjourned. Thank you. Have a good afternoon.