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CMS on actuarial value and cost sharing reductions

Actuarial Value: Why It Matters And How It Will Work

By Lynn Quincy
Health Affairs Blog, February 28, 2012

On February 24, 2012, the Department of Health and Human Services (HHS) released guidance describing a proposed method for estimating the actuarial value of health plan benefit designs in 2014. The actuarial value measures the percentage of expected medical costs that a health plan will cover. It can be considered a general summary measure of health plan generosity. As such, it can help consumers make sense of their health plan options by providing an overall measure of coverage in addition to discrete information on deductibles, copayments, and coinsurance, etc.

A Trade-Off Between Simplicity And Accuracy
 
The bulletin highlights — but doesn't resolve — a tension between simplicity and accuracy in the estimation of actuarial value. HHS initially proposes to use a "practical and easy-to-use" calculator that would utilize the "handful" of cost-sharing features that have a large impact on a plan's actuarial value, such as deductible, co-insurance, and maximum out-of-pocket. This approach may not take into account more subtle features of a plan, such as service specific deductions or exceptions to the out-of-pocket limit.

There are trade-offs, however, from taking this "practical" approach.  First, cost-sharing features that may be only worth a few points of actuarial value can have a big impact on an individual consumer's cost-sharing obligations. Second, high level plan features like the maximum out-of-pocket can vary in how reliably they reflect patient cost-sharing. One study found that plans with similar reported out-of-pocket maximums actually differed by thousands of dollars in the final cost to patients due to exceptions to the maximum.

Third, by opting for a simple calculator, HHS envisions insurers using supplementary methods to calculate actuarial value if their plan design doesn't fit neatly into the calculator. This could greatly undermine the goal of using a common method of calculating actuarial value to ensure that plan comparisons are truly "apples to apples." A recent study demonstrated that the same plan design can yield different actuarial value estimates, if different methods are used to calculate it.

Addressing A Tension Between Actuarial Value And Out-Of-Pocket Maximums

Depending on the actuarial model being used, some researchers have found it impossible to hit the required actuarial value targets and the lower out-of-pocket limit requirements simultaneously. While it may seem counter-intuitive, allowing for a higher out-of-pocket maximum means lower deductibles can be offered while still hitting the required actuarial value target. As many consumers will not hit their out-of-pocket maximum, flexibility to use higher out-of-pocket limits benefits a greater number of consumers.

In a nutshell, HHS proposes to let actuarial value targets trump maximum out-of-pocket rules if this conflict arises. HHS intends to publish an annual notice providing guidance as to the out-of-pocket levels that would be consistent with the actuarial value targets for households with incomes from 100 percent to 250 percent of FPL, presumably reflecting the types of estimates being produced by the federal calculator. For households with incomes of 250 percent to 400 percent of FPL – which are also entitled to lower out-of-pocket maximums under the ACA but remain tied to the standard actuarial value benchmark of 70 percent – HHS proposes to do away with the requirement for lower out-of-pocket maximums altogether.

http://healthaffairs.org/blog/2012/02/28/actuarial-value-why-it-matters-and-how-it-will-work/

CMS: Actuarial Value and Cost-Sharing Reductions Bulletin (16 pages):
http://www.cciio.cms.gov/resources/files/Files2/02242012/Av-csr-bulletin.pdf

Comment: 

By Don McCanne, MD

The actuarial value of a health plan represents the average percentage of covered services that a plan is expected to pay for, the balance being paid by the patient. The Affordable Care Act calls for four levels of plans, ranging from 60 percent to 90 percent actuarial values. Cost sharing, such as deductibles, coinsurance, and maximum out-of-pocket amounts, is an important consideration in determining the actuarial value of the plan.

The excerpts above include only two of many complex considerations in trying to standardize rules for establishing actuarial values and associated cost sharing. For instance, in trading off simplicity and accuracy, "plans with similar reported out-of-pocket maximums actually differed by thousands of dollars in the final cost to patients due to exceptions to the maximum." Also, "For households with incomes of 250 percent to 400 percent of FPL – which are also entitled to lower out-of-pocket maximums under the ACA but remain tied to the standard actuarial value benchmark of 70 percent – HHS proposes to do away with the requirement for lower out-of-pocket maximums altogether."

By selecting this model of reform, not only do we compound the administrative excesses in health care financing, we also compound some of the inequities in our system. Policy wonks will want to read the full CMS Bulletin covering these complex issues (link above).

It is hoped that those who continue to push for implementation of ACA will finally realize the futility of their efforts and join us in advocating for equitable, efficient reform for all of us through a single payer national health program.