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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.

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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

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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.

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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.

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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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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

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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

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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).

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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.

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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.

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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.

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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

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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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