Although Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) marketplaces that offered total cost estimators to help consumers select a health care plan encountered issues in the development and implementation of such tools, they concluded cost estimators may generate higher enrollment during the sign-up process, according to a study conducted by The Commonwealth Fund. The authors of the study, Justin Giovannelli and Emily Curran, conducted interviews with marketplace officials, consumer enrollment assisters, technology vendors, and subject matter experts who used cost estimators to understand their experiences with cost estimators, as well as the opinions of those that did not use them.
Availability of cost estimators. To improve the experience of selecting a health plan on ACA marketplaces, policymakers considered tools that would allow consumers to compare critical information about health plans. Cost estimators are designed to provide consumers with a personalized estimate of total cost of their coverage options, including premium, minus the premium tax subsidy, if applicable; plus cost-sharing, the authors explained. As of the date of the study, total cost estimators are available in 45 states and the District of Columbia. Five states do not offer a total cost estimator. Total cost estimators are available on HealthCare.gov and in eight state-run marketplaces.
Benefits of cost estimators. The study concluded that both states with and without cost estimators strongly suggested that marketplaces should have such tools. Marketplace informants using cost estimators reported positive feedback from both consumers and enrollment stakeholders. Some policymakers noted that estimators were a critical component of the enrollment process because they provide a simple way to determine costs and decipher plan options. Others said the tool strengthened customer service and equipped broker and assister communities with potential time-saving processes. Those informants that did not have such tools had an interest in developing an estimator.
Challenges in implementation. The first step marketplaces have to take to obtain a cost estimator is to determine who would build it. Most marketplaces relied on a vendor based on specialization in consumer decision support or a pre-existing vendor relationship, but some chose to build the tool in-house because they preferred to use state-specific data. Marketplaces also had to consider how much detail to include in their estimators. Factors considered in the design methodology were (1) how long it would take for a consumer to use the estimator; (2) how personalized the estimate should be; (3) whether to include anticipated utilization; and (4) whether to provide an estimate based on actuarial analysis of costs incurred by people similar to the consumer.
The study noted that marketplace informants stressed that consumer and assister testing is an essential component of the process. A significant number of assistors were not regularly using the tools because of challenges they faced, including time pressure, insufficient training, a reluctance to change established ways of providing enrollment assistance, and concerns about accuracy.
Study conclusions. The authors provided the following recommendations based on the results of their study:
- The estimator should not be so detailed that it is overwhelming or too complicated or so simple that it does not have much value. Going forward, marketplaces would benefit from more feedback and data analysis.
- Additional testing should be done to evaluate the accuracy and efficacy of the tools.
- Marketplaces may need to do more to engage assisters and establish reasons for using the tool.
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