Dec 11, 2015 - integrated provider network and drug formulary directories, consumer .... extensive data showing which to
2016 HEALTH
INSURANCE EXCHANGES The Good, the Bad, and the Ugly POLI CY RECOMMENDATI ONS TO I MPROVE CONSUMER CHOI CES
AMIT RAO, JOEL WHITE, AND KATIE ALLEN DECEMBER 11, 2015
ABOUT The Clear Choices Campaign The Clear Choices Campaign is a multi-stakeholder advocacy association, representing patients, providers, insurers, employers, and life science companies that is dedicated to improving health care transparency. We advance solutions that empower consumers to make better health care choices, leading to a more robust, more competitive, and less costly health care system.
W E B E L IEVE THERE SHOULD BE Better tools for consumers and employers to make informed decisions. Better data in the hands of more experts to power consumer tools. Better markets in which consumers can use these tools.
1
2016 HEALTH
INSURANCE EXCHANGES The Good, the Bad, and the Ugly CONTENTS
1 2 3 4 5 6 7
© 2015 Clear Choices Campaign. All rights reserved. 2
FOREWORD The Clear Choices Campaign is an advocacy effort of the Council for Affordable Health Coverage, which I help lead. We are dedicated to the idea that improved transparency in health care will empower consumers to make better choices that will, in turn, lower costs and improve health outcomes. To this end, we collectively support changing the laws and regulations that inhibit the use of information in health care. Done well, changes to improve transparency can offer a huge pay-off. According to Don Berwick, the former Administrator of the Centers for Medicare and Medicaid Services, the lack of transparency and competitive pricing was responsible for between $84 billion and $174 billion in wasteful spending last year. While transparency, by itself, will not cure all that ails our uncompetitive health care system, it is a good place to start. The Affordable Care Act’s (ACA) insurance exchanges are tasked with providing consumers with the information and tools they need to maximize the value of their insurance dollars. While the exchanges have made considerable upgrades to their websites since the initial 2014 rollout, there is still substantial room for improvement. Despite the existence and use of private sector technologies like integrated provider network and drug formulary directories, consumer decisions are hampered—needlessly—by websites that do not go far enough to help them make the best possible coverage decisions. Any new program will have its fits and starts, but we should not hobble ourselves by failing to use the best consumer-facing features and tools available. Politically, both Democrats and Republicans see value in transparency. Republicans want markets to work. Democrats want to level the real and perceived imbalances in the playing field. Both parties seem to want an empowered consumer. Therefore, our goal in developing this white paper is to offer constructive and practical recommendations to Congress, the Administration, and state governments for the exchange websites to better support consumer welfare. We believe these reforms will also improve the functioning of markets and enhance competition by better providing the necessary information needed for consumers to make optimal health plan choices. As bigger fights loom over health reform, some in both parties want to identify and work on real problems that are adversely impacting their constituents. We believe improving the exchange websites is an issue both parties can address without creating partisan collateral damage, even in an election year. The Clear Choices Campaign encourages policymakers to do just that. The paper’s primary author, Amit Rao, has done important work and spent countless hours drafting the paper and working on its methodology. For that, I am thankful. I also extend thanks to Paul Hewitt for his editing and methodological assistance, and to Katie Allen for her collaboration in helping to finalize the paper. Finally, many thanks to members of the Clear Choices Campaign for all of their feedback, advice, and counsel in developing this white paper. We all hope it leads to positive change.
Sincerely, Joel C. White President, Clear Choices Campaign
3
INTRODUCTION Consumerism in health care is rapidly evolving, driven by rising costs,
Americans purchase individual health insurance directly from issuers
improved data and information technology, new plan designs, and
or through private insurance exchanges.4
the growing role of online comparison shopping in our everyday lives.
In recent years, a broadening array of plan benefit designs, featuring
The Affordable Care Act’s (ACA) online health insurance exchanges,
complex mixes of premiums, deductibles, consumer cost sharing,
now entering their third year, are intended to offer consumers in
formularies, and “narrow” provider networks, have raised the
themarket for individual coverage a greater ability to view and
stakes for consumers in choosing plans that fit their unique medical,
compare plan choices than before. Yet, how the exchanges present
financial, and geographic circumstances. These designs are intended
plan information plays a major role in the choices consumers make and, indeed, whether they purchase coverage at all.
to
help
curb
wasteful
utilization
and
improve
quality
Although nine in ten privately insured Americans still obtain coverage
care services and providers. However, they also carry risks, particularly
by incentivizing consumers to utilize high-value, in-network health
through the workplace, a growing number are purchasing insurance
if consumers are not properly equipped.
on their own.¹ As of June 30, 2015, 9.9 million individuals were enrolled in health plans available through the ACA’s state-based and federally-
In this context, HealthCare.gov (the federally-facilitated exchange
facilitated exchanges—most of whom receive public subsidies.² The
website, which operates in 38 states) and the 13 state-based exchange
Department of Health and Human Services (HHS) projects that this
websites are tasked with providing consumers with the information
number could reach up to 11.4 million in 2016.³ Another 7-10 million
and tools they need to make informed health plan choices.
4
CLEARCHOICESCAMPAIGN.ORG
WHAT DEFINES A SUCCESSFUL Online Plan Enrollment Experience?
Research suggests that consumers typically need four primary features to best inform their online enrollment choices.6,7 Consumers need to:
1 Easily view, compare, and
2
3
4
Identify their expected
Confirm whether a plan
Navigate the website
understand their health
total plan costs and
covers their preferred
smoothly and complete
plan options.
determine eligibility for
doctors and/or prescribed
the enrollment process
financial assistance.
medications.
quickly.
With these core consumer goals in mind, this paper outlines the Clear Choices Campaign’s assessment of the insurance exchanges, provides a scorecard to grade the 2016 exchange websites (see Appendices), and offers suggestions for improving exchange websites to facilitate better plan choices. The recommendations for exchange websites to better serve the consumer decision-making process and online plan enrollment experience are based on current research and literature, as well as input from an array of consumer-industry stakeholders, including health care consumers, providers, payers, life sciences companies, and employer groups.
5
SUMMARY OF
POLICY RECOMMENDATIONS To Improve Consumer Choices 1
CUSTOMIZED WINDOW-SHOPPING TOOL Allow consumers to preview and compare customized plan choice information based on their personal circumstances prior to creating a user account.
2
SMART, COMPARATIVE PLAN DISPLAY PAGE Display health plan choices optimized to the consumer’s personal circumstances, considering factors such as the type of health plan, total out-of-pocket costs (premiums, deductibles, and cost sharing), eligibility for financial assistance and tax benefits, preferred providers, and prescribed medications.
3
ACCESS TO DETAILED PLAN INFORMATION Provide direct links to plan summaries of benefits and coverage, in-depth information on plan deductibles and cost sharing for health care services, and direct links to plan provider networks and drug formularies that allow consumers to easily toggle back and forth without leaving the window-shopping experience.
4
OUT-OF-POCKET COST CALCULATOR Include a tool that provides an estimate of total annual out-of-pocket costs (premiums, deductibles, and cost sharing) customized to the consumer’s health condition, anticipated health care usage, and prescribed medications.
5
I NTEGRATED PROVIDER AND DRUG DIRECTORY TOOLS Utilize integrated provider and drug directories that allow consumers to easily determine which plans cover their preferred doctors and to assess the coverage tier and cost sharing for their prescribed medications under each plan.
6
USER-FRIENDLY WEBSITE LANGUAGE AND NAVIGATION Provide a user-friendly, intuitive website layout that uses clear language that is free of jargon, requires a small number of steps to access key information, and simplifies consumer decision-making.
7
ACCURATE PLAN INFORMATION Information on benefits, cost sharing, provider networks, and drug formularies should be as accurate, current, and consistent as possible, updated no less frequently than on a monthly basis.
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CLEARCHOICESCAMPAIGN.ORG
1
CUSTOMIZED Window-Shopping Tool
CONSUMER GOALS
Allow consumers to preview and compare customized plan choice information based on their personal circumstances prior to creating a user account. Much like shopping for plane tickets or other services, consumers value the opportunity to easily browse their choices before creating a user account that requires significant personal information. During the first open enrollment period, many consumers expressed frustration at having to create user accounts before being able to view health plans. Such front-end requirements may deter individuals from shopping for coverage. To mitigate this problem, 13 of the 14 exchange websites (including HealthCare.gov) have adopted tools designed to allow consumers to “window-shop” available plan choices. Window-shopping tools, however, should allow for customization, so that consumers can quickly identify those plans most appropriate to their unique medical, financial, and geographic circumstances. The exchange websites vary in this regard. HealthCare.gov and nine of the state-based exchanges permit some degree of customization, whereas at least two exchange websites have no capacity for customization.8
R E COMMENDATI ONS
All exchange websites should provide a window-shopping tool
Exchange websites should clearly indicate that entering more
that allows consumers to preview and compare plan choice
personal information will enable the window-shopping tool to
information prior to creating a user account.
display increasingly customized plan options that better reflect their health care needs and eligibility for financial assistance.
The window-shopping tool should allow consumers to input varying degrees of personal information (e.g., age, household size, and income) to determine their eligibility for premium subsidies and Cost-Sharing Reductions (CSRs), and to view customized plan choice information that reflects this financial determination.9
7
2
SMART, COMPARATIVE Plan Display Page
CONSUMER GOALS
Display health plan choices optimized to the consumer’s personal circumstances, considering factors such as the type of health plan, total out-of-pocket costs (premiums, deductibles, and cost sharing),eligibility for financial assistance and tax benefits, preferred providers, and prescribed medications. The default order in which plans are displayed and the sorting
Exchange websites should implement a smarter strategy for
tools available to consumers can play an important role in shaping
displaying plan options and offering tools to help consumers
choices. The default displays of seven exchange websites (including
choose a health plan that works best for them. Evidence suggests
HealthCare.gov) are ordered by premium cost. This default display
navigating through all potential health plan options can be confusing
encourages consumers to choose plans based on premiums alone
and overwhelming for consumers, anmost exchange websites do not
and, hence, undervalue key factors that affect total costs, such as
offer sufficient support on the plan display page to help consumers
deductibles, cost sharing, and coverage networks. For example, plans
quickly identify high-value options that may best meet their needs.
with the lowest premiums will not always be the least costly option
In contrast, best-in-class private insurers and exchangesi use “smart
for consumers with significant medical needs. In addition, website sort
tools” that walk consumers through the tradeoffs among different
options typically are limited to only on a few basic criteria beyond cost,
types of plans and organize the display of options according
such as plan metal tiers, types (e.g., Health Maintenance Organizations)
to best-fit. Many of these private websites have been in operation for
and issuer. Finally, HealthCare.gov and eight state exchanges
years prior to the launch of the ACA insurance exchanges and have
automatically steer those eligible for CSRs to the Silver plans that
extensive data showing which tools and designs best support
offer those benefits, while five states do not. Without such guidance,
consumer preferences and plan selection needs. The federally-
consumers may be less likely to choose the most affordable options, or
facilitated and state-based exchange websites can draw from the
even to enroll in the first place. 10
private sector’s substantial experience in this area.
i
Examples of best-in-class private exchange websites include eHealth, GetInsured, GoHealth, HealthCare.com, HoneyInsured, and Stride Health.
Details on the appropriate level of patient information needed for exchange websites to provide accurate out-of-pocket cost estimates are specified in the Out-of-Pocket Cost Calculator section. ii
8
CLEARCHOICESCAMPAIGN.ORG
2
SMART, COMPARATIVE Plan Display Page R E COMMENDATI ONS The default plan order should be based on a “Smart Sort” that incorporates a number of factors, including consumer preferences and the total annual out-of-pocket (premiums, deductibles, and cost sharing) cost estimateii for each plan.11 Allow consumers to sort and filter plans based on an expanded set of factors, including plan deductibles, eligibility for CSRs, and consumer preferences for providers and prescription drugs.12 Allow consumers to easily select several plans and compare premiums, deductibles, cost sharing, total annual out-ofpocket cost estimates, plan benefits, quality ratings, and coverage of preferred providers and prescribed medications in a side-by-side format.13 Clearly flag plans with tax benefits—premium subsidies, CSRs, and HSAs—for consumers eligible to receive financial assistance.14 In particular, automatically prioritize Silver plans for consumers determined eligible for CSRs. Utilize “smart tools” that walk consumers through the tradeoffs of different types of plans and prioritize the display of health plans based on the consumer’s input to quickly highlight best-fit options.15 Some consumers may be overwhelmed by too many plan choices, in which case a smart interactive tool can help in identifying high-value plan options.16 Exchange websites should consider adopting or building from numerous smart tools already in use by the private sector. iii Plan quality ratings should be provided alongside cost information for each plan to facilitate appropriate plan comparisons.17,18
See this article for more information: “What Expedia, Kayak could teach the ACA exchanges.” FierceHealthPayer, 4 Nov 15. http://www.fiercehealthpayer.com/story/what-expedia-kayakcould-teach-aca-exchanges/2015-11-04.
iii
9
3
ACCESS TO Detailed Plan Cost and Benefit Information CONSUMER GOALS Provide direct links to plan summaries of benefits and coverage, in-depth information on plan deductibles and cost sharing for health care services, and direct links to plan provider networks and drug formularies that allow consumers to easily toggle back and forth without leaving the window-shopping experience.
To help consumers better understand their health plan options, exchange websites should directly provide detailed information on each plan’s cost and benefit structures. While all exchange websites now include links to insurer-provided summary of benefits and coverage documents, the overview of cost and benefit information on the exchange websites themselves still need significant improvement. Notably, the detailed plan information does not always clearly specify which products and services are subject to the plan’s deductible. When consumers do not understand how a plan deductible may affect their cost sharing—especially for common benefits such as physician visits and prescription drugs—the result is unnecessary confusion and unexpected costs. In addition, the federally-facilitated and state-based exchange websites offer consumers only limited flexibility to customize the cost-sharing information based on their expected levels of health care utilization. Another common weakness is that the websites do not always indicate the financial implications of seeking health care services out-of-network, which, in most cases, is significant.¹⁹ Exchange websites should present easy-to-understand plan information directly following the exchange’s main display page. Consumers should be able to quickly find comprehensive plan information on the exchange website or from the issuer directly as needed.
R E COMMENDATI ONS
Provide direct links on the plan display page to summaries of benefits
Clearly identify preventive services as requiring no cost sharing
and coverage, detailed information on deductibles and cost sharing,
for the consumer.22
provider networks, and prescription drug formularies.
20
Alert consumers to the risk of higher cost sharing for health care
Clearly highlight all specific services subject to or exempt
services accessed out-of-network.23
from a plan deductible to ensure that consumers accurately
The detailed plan information should clarify the benefit
perceive their expected cost sharing.21
structure that applies for the type of out-of-network care
If a plan has a separate medical and drug deductibles, clearly
(e.g., 20% coinsurance) and indicate whether consumer
specify which deductible applies for which services and how the
payments for such care would count towards the plan
deductibles relate to each other.
deductible and out-of-pocket maximum.
Clearly specify how deductibles differ in application for
Provide direct links to the specific plan page on insurer websites
individuals or a family enrolled in a plan, if applicable (e.g.,
for consumers that wish to obtain more information about
total plan deductible versus a per-person deductible for
certain plans.24
family coverage).
10
CLEARCHOICESCAMPAIGN.ORG
4
OUT-OF-POCKET Cost Calculator CONSUMER GOALS Include a tool that provides an estimate of total annual out-of-pocket costs (premiums, deductibles, and cost sharing) customized to the consumer’s health condition, anticipated health care usage, and prescribed medications. When displaying plan options, exchange
each plan’s benefit structure would affect a
calculation for each family member applying
websites
consumer’s expected annual costs.
for coverage. Estimates based on such
their
should
expected
help
consumers
out-of-pocket
calculate
costs
and
general levels of detail can significantly
assess the cost tradeoffs of different health plan
For the 2016 Open Enrollment period, five
understate the plan’s expected total out-of-
options.
exchange
exchange websites (including HealthCare.
pocket costs. The most accurate calculators,
websites (eight of 13, excluding Vermont Health
gov) have added a new Out-of-Pocket Cost
such as the tool used by the Kentucky exchange
Connect) do not include a tool that helps
Calculator designed to help consumers better
(Kynect), allows consumers to specify known
consumers calculate or compare estimates of
understand their expected plan costs. In
health conditions, anticipated health care
their total annual out-of-pocket costs, including
most cases, though, consumers are not given
procedures,
remiums, deductibles, and cost sharing.
the option to provide the extensive detail
Exchange websites should allow consumers
Currently, these websites generally allow
needed to make reliablecost estimates. For
the option of entering specific health informa-
consumers to view cost-sharing policies
example,
allows
tion and provide an easy comparison of such
for various categories of care, and to make
consumers to select a general preset range
customized out-of-pocket cost estimates across
eyeball comparisons between several plans,
of expected health care utilization (low/
all applicable plans.
but these features provide little detail as to how
medium/high)
At
present,
most
HealthCare.gov
to
be
11
only
factored
into
the
and
prescribed
medications.
4
OUT-OF-POCKET Cost Calculator R E COMMENDATI ONS Include an Out-of-Pocket Cost Calculator tool that provides an estimate of total annual out-of-pocket costs (premiums, deductibles, and cost sharing) customized to the consumer’s health and financial status.25, 26 Specify that the total annual out-of-pocket cost estimate provided on the exchange website includes premiums, deductibles, and cost sharing. Distinguish this cost estimate from information provided on the plan out-of-pocket maximum, as defined in the ACA statute as the limit consumers can pay towards the plan deductible and cost sharing (premiums excluded). Allow consumers to provide input on all of the following factors for each family member applying for coverage: common or known health conditions, anticipated health care procedures/usage, and prescribed medications. Although optional, exchange websites should clearly indicate to consumers that entering more health information will enable the tool to provide increasingly customized and accurate out-of-pocket cost estimates. The tool should support consumers on the plan display page in more easily comparing the estimate of total annual out-of-pocket costs between health plan options to better assess the potential tradeoffs between premiums, deductibles, cost sharing, and benefits. Provide the Out-of-Pocket Cost Calculator tool methodology as open-source for stakeholders to review and suggest improvements for the accuracy of cost estimates. Exchange websites may also consider including an Individual Mandate Penalty Calculator that accurately estimates the fee consumers may face if they choose not to purchase qualified coverage.
12
CLEARCHOICESCAMPAIGN.ORG
5
INTEGRATED PROVIDER And Drug Directory Tools
CONSUMER GOALS
Utilize integrated provider and drug directories that allow consumers to easily determine which plans cover their preferred doctors and to assess the coverage tier and cost sharing for their prescribed medications under each plan. A chief concern for consumers when evaluating plan options is determining whether their doctor or preferred hospital
RECOMMENDATI ONS
participates in their plan. They also want to know if their prescribed medications are covered and what their costsharing obligations might be on the plan formulary. In most cases, exchange websites provide direct links to plan
Include built-in tools (i.e., non-external site) that provide a
provider networks and formulary directories hosted on the
standardized, user-friendly means for consumers to easily
insurer’s website, a method that limits consumers’ ability to
search for and compare health plans that cover their preferred
quickly search for and compare all plan options that include
providers and prescribed medications. 29
their particular providers or prescription drugs.
27
The tools should allow consumers to enter multiple For the 2016 Open Enrollment period, three exchange websites
providers and/or drugs into one search, indicate coverage on
include integrated provider search tools, while six include
the plan display page while window-shopping, and provide a
integrated drug search tools. These tools allow consumers to
filter to highlight plans which cover the consumer’s preferred
quickly determine whether plans cover their preferred providers
providers and/or prescribed medications.30, 31
and prescribed medications.
27
In most cases, however, they
do not include filters designed to highlight all of the plans
Consumers should have several options to vary, sort, and filter
being offered that cover the consumer’s preferred providers and
their search results, including, but not necessarily limited to:32
prescribed medications. In addition, the integrated drug
Provider networks: provider type (e.g., primary care,
directories generally do not includeessential information on
specialist), facility type (e.g., physician office, hospital), and
coverage tier and cost sharing for the consumer’s prescribed
distance (e.g., based on the consumer’s location); and
medications.
Drug formularies: Medication dosage level (if desired, but Exchanges should include integrated provider and drug
not required), generic drug availability, coverage tier, and
directory tools that help consumers easily search for, filter, and
utilization management restrictions, if applicable.
compare plans that cover their preferred providers and prescribed medications, as well as access coverage tier and cost-sharing
Integrated drug directories should indicate prescription drug
information for prescription drugs.
coverage with coverage tier and cost-sharing information (similar to the Medicare Drug Finder). Consumers should be able to access the integrated provider and drug directory tools from the plan display page.33 State-based exchange websites should make their integrated irectory data available for public use in a machine-readable format, similar to the availability of the Application Program Interface (API) for HealthCare.gov.
13
6
USER-FRIENDLY Website Language and Navigation
CONSUMER GOALS
Provide a user-friendly, intuitive website layout that uses clear language that is free of jargon, requires a small number of steps to access key information, and simplifies consumer decision-making. When using exchange websites, consumers seek to easily navigate website platforms, understand the information presented, and quickly complete the enrollment process. Website language and layout should make the often complicated choices involved as easy as possible.34 Some exchange websites provide cluttered layouts, require too many clicks to obtain needed enrollment information, and rely too heavily on complicated text when visuals might better accomplish the same purpose. In addition, while HealthCare.gov offers a mobile phone layout option, not all state-based exchange websites support mobile accessibility, which may create barriers for consumers who primarily utilize smartphones to access the Internet.35 User-friendly website navigation should also include accessibility for multiple major languages. Two of the 13 state-based exchanges do not offer any non-English language assistance, while seven exchange websites (including HealthCare.gov) support only Spanish. In addition to Spanish, the major languages commonly supported in the private sector include Chinese, Russian, Tagalog, French, German, and Hindi. The lack of accessibility on exchange websites needlessly limits enrollment by consumers with limited English proficiency. Currently, exchange websites vary significantly in how user-friendly they are across platforms and all may benefit from improvements to comprehension, layout, accessibility, and consumer support.
14
CLEARCHOICESCAMPAIGN.ORG
6
USER-FRIENDLY Website Language and Navigation R E COMMENDATI ONS Have an intuitive design and layout. Consumers may
Provide easy-to-follow (walkthrough or hover-over)
have more difficulty following content if the words are
definitions of key plan display page features and terms.
difficult to read (due to font size, spacing, or color) or if
If consumers need additional help, provide supporting
the layout is too cluttered.
links, interactive tutorials, and connections to
36
insurance brokers.43 Require minimal clicks from the homepage to access the window-shopping tool and other key plan and
Provide language accessibility support across multiple
enrollment information.
languages to help non-English consumers to enroll
37
in coverage.44 Websites should prominently flag how Use plain and concise language that is free of academic,
consumers can obtain assistance in other languages
bureaucratic, or legalistic jargon.38 A “living room”
on the website homepage.45
conversational tone will reach consumers more effectively than a technical tone. Include tutorials when use of insurance jargon in required that helps provide a clear definition of the term. Break up and highlight important content by using bolds, italics, underlines, section headers, checklists, numbers, bullets, and arrows. 39 Utilize a progress bar to guide the consumer through multiple steps and indicate which stage of the plan selection process they are in screen-by-screen.40, 41 Use visuals (images, graphs, tables) to help clarify plan information.42 Generally, the less text and more visuals, the better for consumer viewing comprehension.
15
7
ACCURATE Plan Information
CONSUMER GOALS
Provide a user-friendly, intuitive website layout that uses clear language that is free of jargon, requires a small number of steps to access key information, and simplifies consumer decision-making. plan
discrepancies between plan names on the
provider is in-network, only to later discover
information is a primary function for all
exchange websites and on an insurer’s website,
that the provider no longer contracts with the
exchange
is
which may complicate consumer efforts to
plan. Similar problems arise less frequently with
plans
At
their
core,
delivering
websites.
accurate
Information
that
obtain assistance with a particular plan.
prescription drug formularies, though they
may erode trust or do actual harm by
Consumers
plan
remain a concern. Inaccurate or outdated
facilitating decisions at odds with a consumer’s
overview page found on the exchange website,
information regarding provider or prescription
best medical or financial interests. In this
whereas plans strictly adhere to plan contracts,
drug coverage can be particularly disruptive
regard, consumers and navigators have raised
whose information is summarized in detail for
for consumers.48 Accurate directories require
concerns about the reliability of certain
consumers in the summary of benefits and
information to be shared both ways among all
health plan information presented on the
coverage document. Such inconsistencies have
entities involved.
exchange websites. 46
the potential to negatively impact consumer
inaccurate
or
inconsistent
across
generally
look
at
the
Exchange
decision-making. 47 Inconsistencies between a website’s plan
websites
should
take
further
measures, in conjunction with plans, providers,
overview page and a plan’s summary of benefits
Consumers also have reported issues with
and regulators, to ensure that the plan
and coverage—particularly with respect to the
the accuracy of information on plan provider
informationpresented to consumers is accurate,
application of a plan deductible and cost sharing
networks and drug formularies presented on
consistent across multiple sources, and updated
for health care services—are a well-documented
exchange websites. In these cases, consumers
on at least a monthly basis.49
problem. In addition, there are sometimes
typically select a plan believing their preferred
R E COMMENDATI ONS
Ensure that plans provide consistent information
Require plan provider networks and drug
across the website plan overview page, the underlying
formularies to have accurate and consistent data,
plan summary of benefits and coverage document,
updated no less frequently than on a monthly basis.53
and plan contracts.
50
Include “last modified” timestamps on the plan Regularly spot check the accuracy of plan information,
display page to indicate to consumers when the plan
particularly for data on benefits, cost sharing, provider
information available was last updated by the insurer.
networks, and drug formularies.
51
Provide an easy means for consumers to report potential inconsistencies they observe with plan information for review.52
16
CLEARCHOICESCAMPAIGN.ORG
CONCLUSION Going into the 2016 Open Enrollment period, HHS has identified
and compare plans that provide the best coverage for their
approximately 10.5 million uninsured Americans who were eligible
preferred doctors and/or prescribed medications. Finally, to provide
for exchange plan coverage in 2015 but did not enroll.54 To help
consumers with an efficient and effective overall enrollment
reach this untapped market and better match consumers with
experience, exchange websites should encourage accessibility
plans that meet their health care needs and financial circumstances,
through user-friendly language and website navigation and
exchange websites should work towards best practices in providing
ensure validity through accurate plan information across all pages.
the kinds of information and tools consumers need in order to
Given that many of these features have already been developed
effectively comparison shop and enroll in coverage.55
and utilized on private exchange websites, HHS should consider incorporating or contracting out certain consumer-facing features
To this end, exchange websites should provide customized
to the private sector.
window-shopping tools and utilize smart, comparative plan display pages. Exchange websites should incorporate Out-
Empowering consumers to effectively evaluate and compare
of-Pocket Cost Calculator tools that provide a customized
health plan choices is critical to ensuring they have the best
estimate of total annual out-of-pocket costs—including premiums,
chance to select a plan that meets their needs. Better information
deductibles, and cost sharing—to help consumers clearly identify
on coverage options can help reduce costs and improve health
their expected plan costs and eligibility for financial assistance.
outcomes. By adopting the recommendations outlined in this
Exchange websites should also utilize integrated plan provider
paper, exchange websites can reduce costs for consumers and
and drug directories, to allow consumers to easily search for
taxpayers alike.
17
APPENDICES
18
CLEARCHOICESCAMPAIGN.ORG
SMART, COMPARATIVE PLAN DISPLAY PAGE
YEARLY COST ESTIMATE
A
YES
YES
YES
YES
YES
YES
YES
YES
NO
DC HEALTH LINK
MARYLAND HEALTH CONNECTION
HEALTHSOURCE RI
MNSURE
YOUR HEALTH IDAHO
CONNECT FOR HEALTH COLORADO
MASSACHUSETTS HEALTH CONNECTOR
NEW YORK STATE OF HEALTH
VERMONT HEALTH CONNECTION
PREMIUMS
A
N/A*
PREMIUMS
PREMIUMS
N/A*
YES
YES
YES
N/A*
NO
NO
NO
NO
NO
YES
YES
NO
N/A*
NO
NO
NO
YES
YES
YES
YES
NO
NO
YES
YES
YES
YES
N/A*
F
F
F
N/A*
F
C
A
F D
F iv
F
F
A
B
F
F
A
A
B
C
F
B
C
F
B
F
A
N/A*
F
F
A
F
F
F
F
F
C
F
F
F
B
N/A*
C
C
A
B
A
C
B
A
A
B
B
A
B
INTEGRATED INTEGRATED PROVIDER DRUG DIRECTORY DIRECTORY LAYOUT
F
A
A
B
B
F
B
F
F
B
A
B
B
A
LANGUAGE ACCESSIBILITY
USER-FRIENDLY NAVIAGTION
*N/A: Indicates that the exchange website features were not accessible for evaluation because the website did not offer a window-shopping tool. **Indexed Weighted Composite Score Your Health Idaho’s Out-of-Pocket Cost Calculator only provides a “Low,” “Medium,” or “High” cost estimate for each plan, which offers lower utility than a specific dollar amount for consumers.
N/A*
B
F
PREMIUMS
YEARLY COST ESTIMATE
A
F
YES
PREMIUMS
A
YES
YES
SMART SORT
A YES
YES
NO
YES
PREMIUMS
A
YES
HEALTHCARE.GOV
YES
A
YES
COVERED CALIFORNIA
YES
YES
NO
YES
YES
SMART SORT
A
YES
ACCESS HEALTH CT SMART SORT
YES
PREMIUMS
A
YES
YES
YEARLY COST ESTIMATE
WASHINGTON HEALTHPLANFINDER
A
YES
iv
OUT-OFPOCKET COST
SMART ANONYMOUS CUSTOMIZED DEFAULT SIDE-BY-SIDE HIGHLIGHTS CALCULATOR PLAN BROWSING PLAN INFO ORDER COMPARISONS CSR PLANS FINDER
WINDOW-SHOPPING TOOL
Websites Scorecard
2016 INSURANCE EXCHANGE
KYNECT
INSURANCE EXCHANGE WEBSITE
A
APPENDIX
N/A*
30
35
55
59
61
63
63
63
63
64
71
74
84
INDEXED SCORE**
APPENDIX
SCORECARD
B
Methodology The exchange website analysis for the scorecard was conducted between November 17-25, 2015, using window-shopping tools as available.
OVERVIEW SCORI NG SYSTEM Each column is scored based on one of the following metrics, depending on the column’s particular criteria as outlined below. Yes/No: Provides a simple binary classification to indicate whether the question is satisfied. Categorical Variable: Specifies the type of feature in use by the exchange website out of a defined set of options. Letter Grade: Indicates the level of proficiency at which the criteria are satisfied. Generally, the letter grades are scored as follows. Underlined text in the criteria description indicate key factors for distinguishing between scoring grades. A
Meets all criteria for this category.
B
Meets most criteria for this category.
C
Meets some criteria for this category.
D
Meets minimal criteria for this category and provides little utility to the consumer in their current construction.
F
Meets none of the criteria for this category (e.g., the feature is not provided).
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CLEARCHOICESCAMPAIGN.ORG
CRITERIA ANONYMOUS BROWSING (YES/NO)
SIDE-BY-SIDE COMPARISON S (YES/NO):
Allow consumers to preview and compare customized plan choice information based on their personal circumstances prior to
Indicates whether the plan display page allows consumers to
creating a user account.
select plans and compare benefits and cost-sharing information side-by-side.
CUSTOMIZED PLAN INFO (LETTER GRADE):
SMART PLAN FINDER (YES/NO): allows
Indicates whether the plan display page includes a “smart tool”
consumers to input their personal information (age, household
that prioritizes the display of health plans based on the consumer’s
size, and income) to determine eligibility for financial assistance
input to quickly highlight best-fit options.
Indicates
whether
the
window-shopping
tool
and access customized plan choice information. A
HIGHLIGHTS CSR PLANS (YES/NO):
Determines the consumer’s eligibility for premium
Indicates whether the plan display page highlights Silver plans
subsidies and Cost-Sharing Reductions and provides
by default for consumers eligible for Cost-Sharing Reductions.
customized plan choice information based on these financial determinations. B
OUT-OF-POCKET COST CALCULATOR
Determines the consumer’s eligibility for premium
Indicates whether the exchange website includes a tool that
subsidies only and provides customized plan choice
provides an estimate of total annual out-of-pocket costs
information based on this financial determination. C
(premiums, deductibles, and cost sharing) customized to the consumer’s health and financial status.
Determines the consumer’s eligibility for premium subsidies and/or Cost-Sharing Reductions but does not provide customized plan choice information based on
A
this financial determination. F
Allows consumers to provide input on all of the following factors for each family member applying for coverage: common health conditions, anticipated health care
Does not allow consumers to input personal information
procedures/usage, and prescribed medications.
to determine eligibility for financial assistance and access customized plan choice information within the
B
window-shopping tool.
Allows consumers to provide input on some of the following factors for each family member applying for coverage: common health conditions, anticipated health
DEFAULT ORDER (CATEGORICAL VARIABLE):
care procedures/usage, and prescribed medications. C
Specifies the default order in which plan options are
Allows consumers to select a general preset range of expected health care utilization (e.g., Low/Medium/High)
displayed. Options include “Premiums,” “Yearly Cost Estimate,”
or general health status (e.g., Poor/Moderate/Good) only
and “Smart Sort.”
for each family member applying for coverage.
“Smart Sort” indicates that the default plan order
F
Does not include a tool to provide consumers with a customized estimate of total annual out-of-pocket costs.
incorporates a number of factors, including consumer preferences and the total estimated annual out-of-pocket costs (premiums, deductibles, and plan cost sharing).
21
INTEGRATED PROVIDER DIRECTORY (LETTER GRADE):
LAYOUT (LETTER GRADE):
Indicates whether the exchange website includes a built-in tool
and provides easy explanations of terms for consumers.
Indicates whether the exchange website has an intuitive design
(non-external site) that allows consumers to search for plans that
A
cover their preferred providers. A
Requires minimal clicks from homepage to access the window-shopping tool, and includes all of the following
Indicates provider coverage on the plan display page
items: plain and concise language, a progress bar while
while window-shopping and provides a filter to highlight
entering personal information (if multiple pages), easy-
plans that cover the consumer’s preferred providers.
to-follow (walkthrough or hover-over) definitions of key features/terms, and a lack of clutter.
B
Indicates provider coverage on the plan display page B
while window-shopping but does not provide a filter
C
to highlight plans that cover the consumer’s preferred
window-shopping tool, and includes most of the
providers.
following items: plain and concise language, a progress bar while entering personal information (if multiple
Allows consumers to search for plans that cover their
pages), easy-to-follow (walkthrough or hover-over)
preferred providers but does not indicate provider
definitions of key features/terms, and a lack of clutter.
coverage on the plan display page while windowshopping and does not provide a filter to highlight plans
C
that cover the consumer’s preferred providers. F
Requires minimal clicks from homepage to access the
Requires minimal clicks from homepage to access the window-shopping tool, and includes some of the
Does not include a built-in tool for consumers to search
following items: plain and concise language, a progress
for plans that cover their preferred providers.
bar while entering personal information (if multiple pages), easy-to-follow (walkthrough or hover-over)
INTEGRATED DRUG DIRECTORY (LETTER GRADE):
definitions of key features/terms, and a lack of clutter. F
Indicates whether the exchange website includes a built-in tool
Does not require minimal clicks from homepage to access the window-shopping tool, and includes few of
(non-external site) that allows consumers to search for plans that cover their prescribed medications.
the following items: plain and concise language, a
A
Indicates prescription drug coverage, with coverage tier
multiple pages), easy-to-follow (walkthrough or
and cost-sharing information, on the plan display page
hover-over) definitions of key features/terms and a lack
while window-shopping and provides a filter to highlight
of clutter.
progress bar while entering personal information (if
plans that cover the consumer’s prescribed medications. B
LANGUAGE ACCESSIBILITY (LETTER GRADE):
Indicates prescription drug coverage, without coverage tier and cost-sharing information, on the plan display page while window-shopping and provides a filter to
Indicates whether the exchange website prominently features
highlight plans that cover the consumer’s prescribed
non-English language assistance.
medications. C
A
Indicates prescription drug coverage, without coverage
for multiple languages.
tier and cost-sharing information, on the plan display
B
page while window-shopping but does not provide a filter
Displays language support prominently on the homepage for a single language (usually Spanish).
to highlight plans that cover the consumer’s prescribed F
medications. F
Displays language support prominently on the homepage
Does not display language support on the homepage, does not provide language support through the website,
Does not include a built-in tool for consumers to search
or relies on basic google translation for language support.
for plans that cover their prescribed medications.
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CLEARCHOICESCAMPAIGN.ORG
INDEXED WEIGHTED COMPOSITE The central finding of the 2016 Insurance Exchange Websites Scorecard is that the various exchange websites differ widely in their functionality and in how effectively they help consumers identify and select the health plans that best fit their unique circumstances. There is a question as to how meaningful those differences are, however. To help answer this, the final column of the scorecard provides a measure of relative functionality in the form of an indexed weighted composite. On this index, the highest possible score is 100. As shown in Table B-1, most exchange websites are clustered in the middle of the distribution. HealthCare.gov, which operates in 38 states, has a score of 63, which also happens to be the median. Overall, there are clear leaders and laggards among the exchange websites.
TAB L E B -1 : IN DE X E D WEI GHTED COMPOSI TE SCORES
84
KY NE C T In developing this composite, we weighted each of
74
WAS H I N GTO N H E ALT H PLANFINDE R
the 11 primary features evaluated in this study on a scale of 1 to 10, based on our assessments of their relative importance. We weighted seven of the 11
71
ACC E SS H E A LT H C T
64
COV E R E D C AL I F O R N I A
63
H E ALT H C A R E .GOV
63
DC H E ALT H L I NK
63
MARY L AND H E A LT H CO N NE CT IO N
63
H E ALT H S O U R C E R I
features as 10. Two features—“Default Order” and “Highlights CSR Plans”—we weighted as 8; while two other features—“Side-by Side Comparisons” and “Language Accessibility”—we rated as 5. For example, most of the websites provide Spanish language accessibility. Therefore, we felt that support for, say, Chinese or Tagalog (the third and fourth most widely spoken languages in the U.S.), was not on par with providing a window-shopping tool or Out-of-Pocket Cost Calculator. Those features with an 8 weighting were relatively less important only because other features could allow consumers
61
to accomplish the same or similar tasks with,
MNS U R E
perhaps, another step or two. Had we weighted all factors as 10, the ranking would still be essentially
59
YO U R H E ALT H I DAH O
55
CO NNE C T F O R H E ALT H CO LO RADO
35
MASSACHUSETTS HEALTH CONNECTOR
30
NE W YO R K STAT E O F H EALT H
N/A*
V E R MO N T H E A LT H CO N NE CT
the same, with modest differences in the middle of
23
the distribution.
REFERENCES 1 Levitt, Larry, Cynthia Cox, and Gary Claxton. “Data Note: How Has the Individual Insurance Market Grown Under the Affordable Care Act?” Kaiser Family Foundation, 12 May 2015. http://kff.org/health-reform/issue-brief/data-notehow-has-the-individual-insurance-market-grown-under-the-affordable-careact/
“Web portal to compare health insurance options.” ConsumersUnion, 21 May 2010. http://consumersunion.org/research/web_portal_to_compare_ health_insurance_options/
16
“Report Card on State Price Transparency Laws.” Catalyst for Payment Reform, 25 Mar. 2014. http://www.catalyzepaymentreform.org/images/documents/2014Report.pdf.
17
2 “June 30, 2015 Effectuated Enrollment Snapshot.” Centers for Medicare & Medicaid Services, 08 Sep 2015. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-09-08.html. In its October 15, 2015 update, HHS estimated that 9.1 million would retain their coverage through the years end (see footnote 3).
“Recommendations to Achieve a More Transparent Health Care System for Consumers.” Engelberg Center for Health Care Reform, Brookings Institution, Feb 2015. http://www.brookings.edu/~/media/research/files/papers/2015/02/03-medicare-physician-payment-data/health-policy-brief--recsfor-transparent-health-system.pdf.
18
3 “How Many Individuals Might Have Marketplace Coverage at the End of 2016?” Department of Health and Human Services, 15 October 2015. http:// aspe.hhs.gov/basic-report/how-many-individuals-might-have-marketplacecoverage-at-the-end-of-2016
“Lessons from the Frontlines: Strategies for Supporting Informed Consumer Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Jun 2015. http://www.nationalpartnership.org/research-library/health-care/lessons_from_the_frontlines_strategies_for_supporting_informed_consumer_decisionmaking_in_the_health_insurance_ marketplace_june2015.pdf
19
4 Levitt, Larry, Cynthia Cox, and Gary Claxton. “Data Note: How Has the Individual Insurance Market Grown Under the Affordable Care Act?” Kaiser Family Foundation, 12 May 2015. http://kff.org/health-reform/issue-brief/data-notehow-has-the-individual-insurance-market-grown-under-the-affordable-careact/
“Supporting Informed Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Feb 2015. http://www.nationalpartnership.org/research-library/health-care/supporting-informed-decision-making-in-the-health-insurance-marketplace.pdf. 20
5 Bhargava, Saurabh, George Loewenstein, and Justin Sydnor. National Bureau of Economic Research, May 2015. “Do Individuals Make Sensible Health Insurance Decisions? Evidence from a Menu with Dominated Options.” https:// sites.google.com/site/sbhargav/Bhargava%20Loewenstein%20Sydnor%20 2015_Submission.pdf?attredirects=0
“Lessons from the Frontlines: Strategies for Supporting Informed Consumer Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Jun 2015. http://www.nationalpartnership.org/research-library/health-care/lessons_from_the_frontlines_strategies_for_supporting_informed_consumer_decisionmaking_in_the_health_insurance_ marketplace_june2015.pdf
21
6 “Evaluating the Consumer Window-Shopping Experience in Health Insurance Marketplace Websites: A Comparative Analysis.” FamiliesUSA, Jan 2014. http:// familiesusa.org/sites/default/files/product_documents/state-website-analysis.pdf
22
“Supporting Informed Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Feb 2015. http://www.nationalpartnership.org/research-library/health-care/supporting-informed-decision-making-in-the-health-insurance-marketplace.pdf. 7
8
“Price Transparency in Health Care: Report from the HFMA Price Transparency Task Force.” Healthcare Financial Management Association, Price Transparency Task Force. 2014. http://www.washingtonpost.com/blogs/wonkblog/ files/2014/04/PriceTransparencyReport_2014-final1.pdf.
Ibid.
9
Ibid.
10
Ibid.
11
Ibid.
“Supporting Informed Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Feb 2015. http://www.nationalpartnership.org/research-library/health-care/supporting-informed-decision-making-in-the-health-insurance-marketplace.pdf. 24
25
“Supporting Informed Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Feb 2015. http://www.nationalpartnership.org/research-library/health-care/supporting-informed-decision-making-in-the-health-insurance-marketplace.pdf. 12
Ibid.
15
Ibid.
Ibid.
“Price Transparency in Health Care: Report from the HFMA Price Transparency Task Force.” Healthcare Financial Management Association, Price Transparency Task Force. 2014. http://www.washingtonpost.com/blogs/wonkblog/ files/2014/04/PriceTransparencyReport_2014-final1.pdf. 26
13 “Evaluating the Consumer Window-Shopping Experience in Health Insurance Marketplace Websites: A Comparative Analysis.” FamiliesUSA, Jan 2014. http://familiesusa.org/product/evaluating-consumer-window-shopping-experience-health-insurance-marketplace-websites. 14
Ibid.
23
27
Ibid.
“Lessons from the Frontlines: Strategies for Supporting Informed Consumer Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Jun 2015. http://www.nationalpartnership.org/research-library/health-care/lessons_from_the_frontlines_strategies_for_supporting_informed_consumer_decisionmaking_in_the_health_insurance_ marketplace_june2015.pdf 28
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CLEARCHOICESCAMPAIGN.ORG
29 “Supporting Informed Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Feb. 2015. http://www.nationalpartnership.org/research-library/health-care/supporting-informed-decision-making-in-the-health-insurance-marketplace.pdf.
tionalpartnership.org/research-library/health-care/supporting-informed-decision-making-in-the-health-insurance-marketplace.pdf. 44 “Evaluating the Consumer Window-Shopping Experience in Health Insurance Marketplace Websites: A Comparative Analysis.” FamiliesUSA, Jan. 2014. http://familiesusa.org/product/evaluating-consumer-window-shopping-experience-health-insurance-marketplace-websites.
30 “Lessons from the Frontlines: Strategies for Supporting Informed Consumer Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Jun 2015. http://www.nationalpartnership.org/research-library/health-care/lessons_from_the_frontlines_strategies_for_supporting_informed_consumer_decisionmaking_in_the_health_insurance_ marketplace_june2015.pdf
45 “Supporting Informed Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Feb. 2015. http://www.nationalpartnership.org/research-library/health-care/supporting-informed-decision-making-in-the-health-insurance-marketplace.pdf.
“Web portal to compare health insurance options.” ConsumersUnion, 21 May 2010. http://consumersunion.org/research/web_portal_to_compare_ health_insurance_options/
31
“Lessons from the Frontlines: Strategies for Supporting Informed Consumer Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Jun 2015. http://www.nationalpartnership.org/research-library/health-care/lessons_from_the_frontlines_strategies_for_supporting_informed_consumer_decisionmaking_in_the_health_insurance_ marketplace_june2015.pdf
46
“Lessons from the Frontlines: Strategies for Supporting Informed Consumer Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Jun 2015. http://www.nationalpartnership.org/research-library/health-care/lessons_from_the_frontlines_strategies_for_supporting_informed_consumer_decisionmaking_in_the_health_insurance_ marketplace_june2015.pdf
32
“Price Transparency in Health Care: Report from the HFMA Price Transparency Task Force.” Healthcare Financial Management Association, Price Transparency Task Force. 2014. http://www.washingtonpost.com/blogs/wonkblog/ files/2014/04/PriceTransparencyReport_2014-final1.pdf. 33
“Supporting Informed Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Feb. 2015. http://www.nationalpartnership.org/research-library/health-care/supporting-informed-decision-making-in-the-health-insurance-marketplace.pdf. 34
35
Ibid.
49
Ibid.
50
Ibid.
51
Ibid.
52
Ibid.
“Report Card on State Price Transparency Laws.” Catalyst for Payment Reform, 25 Mar. 2014. http://www.catalyzepaymentreform.org/images/documents/2014Report.pdf.
Ibid.
“Secretary Burwell Previews Third Open Enrollment.” U.S. Department of Health & Human Services, 22 Sep 2015. http://www.hhs.gov/news/ press/2015pres/09/20150922a.html
54
“Communicating With Plain Language.” MAXIMUS Center for Health Literacy, Feb. 2012. https://s3.amazonaws.com/assets.enrollamerica.org/wp-content/ uploads/2013/12/Communicating_with_Plain_Language.pdf
“Lessons from the Frontlines: Strategies for Supporting Informed Consumer Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Jun 2015. http://www.nationalpartnership.org/research-library/health-care/lessons_from_the_frontlines_strategies_for_supporting_informed_consumer_decisionmaking_in_the_health_insurance_ marketplace_june2015.pdf
55
“Report Card on State Price Transparency Laws.” Catalyst for Payment Reform, 25 Mar. 2014. http://www.catalyzepaymentreform.org/images/documents/2014Report.pdf.
37
“Communicating With Plain Language.” MAXIMUS Center for Health Literacy, Feb. 2012. https://s3.amazonaws.com/assets.enrollamerica.org/wp-content/ uploads/2013/12/Communicating_with_Plain_Language.pdf
38
Ibid.
40 “Supporting Informed Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Feb. 2015. http://www.nationalpartnership.org/research-library/health-care/supporting-informed-decision-making-in-the-health-insurance-marketplace.pdf.
“Communicating With Plain Language.” MAXIMUS Center for Health Literacy, Feb. 2012. https://s3.amazonaws.com/assets.enrollamerica.org/wp-content/ uploads/2013/12/Communicating_with_Plain_Language.pdf
41
42
Ibid.
48
53
36
39
47
Ibid.
“Supporting Informed Decision-Making in the Health Insurance Marketplace.” National Partnership for Women & Families, Feb. 2015. http://www.na43
25
CONTACT US 1101 14TH ST. NW, SUITE 700, WASHINGTON, DC 20005 CLEARCHOICESCAMPAIGN.ORG
AUTHORS Amit Rao Senior Policy Analyst Manager of Government Affairs
[email protected] Joel White President
[email protected] Katie Allen Manager of Government Affairs
[email protected]
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