Ma rket Segments

1. Market Segments MEOW #4 September 21, 2011 Prepared by Shana Montrose based on notes from each break-out group discussion from MEOW #3, August 17, 2011.

2. Groups were asked to discuss • We will have demographic data for potential customers from Dr. Gruber in late September. Short of that, what additional information seems most useful? • What messages are most appropriate for this group? Are there significant subgroups? • What strategies should we use to reach people in this group (or in these subgroups)?

3. Facilitator: Heather Hewitt Income and Employment

4. Introduction • Target Population: 133% to 400% of FPL; 13.5% of Coloradoans eligible for the exchange; 39% of Coloradoans were uninsured at some point during the past year • Income is very important – it touches all other groups (age and objectors; race, ethnicity, language, and culture; gender and family composition; and geography and the ways we reach people) • All groups are based on employment and income status so messaging strategies are going to intersect with other groups

5. Subgroups Many segments: • Different / nuanced messages based on reasons why the individual doesn’t have insurance (e.g., can’t afford it, rarely get sick) • Different / nuanced messages based on different employment and income levels • Messages for those who go back and forth between Medicaid and subsidies • Don't assume that if individuals don’t have much money that they’re unsophisticated about making financial choices. Low-income individuals can manage finances well and can make sophisticated decisions.

6. Messages • Affordability: there will be a difference of opinion regarding what they can afford • Shift the attitude of people who don't see this as relevant. Get them to see this is for them. • Use pictures, stories, and person-to-person contact to get to the heart and shift attitudes • Yes, you can have insurance and here’s how. • There are options and financial support. Now there is room for you on the bus. • It’s distinct from Medicaid. • It's easier to enroll than you think. • Consider: What’s in it for me and what’s the cost if I don’t get insurance? • It’s the best buy you can make. It’s a huge bargain. • Without insurance, you're gambling and the exchange now puts odds in your favor – same full-cost coverage at a reduced cost. • Number one cause of bankruptcy is healthcare expenses. Use stats of catastrophic event: How likely? How costly? What does it cost for a broken leg?

7. Outreach Strategies • Employers • Social networks – community groups, churches • Safety-net organizations, “trusted hands” • Elected officials (many people call them regarding issues and they are out in the community speaking to their constituents) • Trusted and esteemed newscasters and sports figures, like Tebow or Elway (can act as visible spokespeople) • Town hall meetings • Local media, including television, radio, newspaper • Schools, including community colleges • Social media like Facebook, YouTube, and Twitter • Search engine marketing • Direct mail • Out-of home advertising

8. Funding • What can federal dollars cover, if anything? • Foundations, trusts, other grants • Build partnerships with news stations, sports teams, and other influential groups to be champions for insurance exchanges

9. Facilitator: Carol Giffin-Jeansonne Age and Objectors

10. Key Points • Two high yield groups were identified: 18-25 year olds and those ages 55-64. • Cost as primary deterrent of insurance coverage in both groups. • Younger adults low end of the pay scale • Seniors: retired, unemployed, or on fixed incomes. • Males 18 - 34 years - higher unemployment and uninsured rates. • Think about style and tone

11. Men • There are more uninsured men in Colorado than women. • Men are less concerned with healthcare in the younger age groups. • Men will likely represent the largest percentage of objector population. • Currently, affordability may be a greater issue for women in terms of access to coverage.

12. Colorado Uninsured Statistics: (from Kaiser State Facts) • Total uninsured ages 19-64: 616,300 % of State population 20% • Total uninsured non elderly adults above 400% FPL: 83,400 • (Likely “objector” population or voluntarily uninsured) • Total uninsured non-elderly adults under 139% FPL 355,300 • (Population that may qualify for Medicaid expansion) • Uninsured adults that could qualify for subsidies): 264,500 • (Under 139% - 400%FPL) • Target population for exchange outreach: 347,900 • Total non elderly adults with Dependents: 181,800 • Total non elderly adults w/o Dependents: 434,500 • Total uninsured non elderly adult men: 337,800 • Total uninsured non-elderly adult women: 278,500

13. What’s changed? • Guarantee Issue • New ratings ratios, age, geography, etc. • Annual and lifetime caps • No rescissions • Etc.

14. Layered Messaging • Layer 1: Notification (You will need insurance coverage or pay a penalty in 2014 and it applies to you unless…..) • Layer 2: Basic information • Layer 3: Detailed information • Layer 4: Interactive information • Use links to move user between layers or identify terminology or concepts

15. Messaging to Young Adults • Convince them they need insurance by presenting some very real, relatable examples when not having insurance is disastrous. • Craig Hospital and catastrophic injuries, perhaps videos • Emphasize injury more than sickness or wellness benefit (“I can get over pneumonia, but not a torn ACL.”) • Need to convey benefit/cost effectiveness of insurance provided at exchange versus just a catastrophic plan. Essential benefits package will inform this (“is it richer than I want?). • TONIK • “How will this benefit me?” • Explain terms, benefits in language they will understand, perhaps in a brochure, etc. (“6th grade reading level, 8th grade listening comprehension level) • Tech modalities: youtube, facebook, google+, twitter, texts • Frame marketing in a way that perhaps stigmatizes not having health insurance (“Dude…Think student loans are bad?”)

16. Ages 18-34: Considerations • Early range of age group has a high uninsured rate. 30% up to age 26 have no health insurance roughly 1.2 million nationally • Early range of age group may be on parent’s coverage until age 26. • This group is more likely to have a volatile employment status • This group will have the lowest income • Cost will be an issue • This group may be the most willing to pay the penalty • On a personal level health coverage will be considered to be less critical of a priority (unless pre-existing condition) • This group will be the least familiar with health insurance concepts and terminology • Attachment to provider networks or individual providers will be limited.

17. Age 18-34: Outreach tools • Insurance industry and organizational marketing. (This will be the single most important outreach mechanism. We need to work closely with and learn (or adopt) marketing strategies from carriers) • PSAs, Web ads • Social Media, facebook, twitter, texting, etc. • You Tube • Universities • Parents with children approaching the end of dependent coverage. • Youth groups and organizations • Faith-based groups and churches • Business groups and HR managers

18. How will it affect me if…? • I’m a student • I’m on my parent’s plan • I’m unemployed or employment is part time • I’m employed and my employer provides affordable coverage • I’m employed but coverage is not affordable? • I’m employed but my employer does not offer coverage or dropped coverage • I’m self-employed

19. How will it affect me? • Why do I have to have health insurance? • What does the government consider affordable for someone like me? In short, how much could I end up paying out of pocket for this • If I choose not to purchase insurance what penalties (not just money) will I be subject to? • When do I have to start thinking about this? • How long can I stay on my parent’s coverage? • Am I ever exempt? • What’s the penalty? • How much will coverage cost? • How do I get coverage and what are my choices or options? • What kind of coverage do I need based upon my current health status and lifestyle? • Will these plans actually cover or help cover my costs if I have a bad accident or injury?

20. Age 18-34: Advantages • Improved affordability compared to current system? • Subsidies and premium tax credits based upon income level • Medical coverage for injuries and accidents. • Catastrophic coverage • Debt and asset protection • Bankruptcy avoidance • Stop gap option between periods of employment.

21. Messaging to Objectors • For objecting older adults real, live representatives may be the best approach for targeted outreach – no marketing campaign is going to convince them. • Emphasize personal responsibility • Emphasize how they could save money by enrolling now versus later • Present data from more sources perceived to be more “neutral” • Educate how seniors can become eligible for financial help • Need to elucidate who will be exempted

22. Age 35-55: Considerations • Interest in the exchange may not be immediate in 2012, 13, or 14. Many will be currently covered by existing plans. That may make the transition somewhat transparent for a large part of this group. • This group will likely have the highest income • This group is more likely to have a stable employment status • This group is more likely to have insurance coverage already • This group will be less willing to pay the penalty than the first group • Health coverage will be a medium to high priority • This group will be familiar with health insurance concepts and terminology • Providers and provider networks will be a higher priority, since they will probably be established in this age group.

23. Age 35-55: Outreach tools • Insurance industry and organizational marketing. (This will be the single most important outreach mechanism. We need to work closely with and learn approaches from carriers) • Brokers, insurance agents and navigators • PSAs, Web ads, Web sites, Printed media • Call centers and (robo-calls?) • Faith-based groups and churches • Businesses, business groups, HR managers • Financial consultants and advisors

24. How will it affect me if…? • I’m unemployed or employment is part time • I’m employed and my employer provides affordable coverage • I’m employed but coverage is not affordable? • I’m employed but my employer does not offer coverage or dropped coverage • I’m self-employed

25. How will it affect me? • How does this affect the plan and coverage that I or my family are currently on? • Does the new law require me to change coverage? • Will these new laws cause my employer to drop my coverage? • Will this new law make it easier for my employer to offer coverage? • Will this new law impact my salary? • Under what circumstances would I have to use an exchange? • What advantages are there in purchasing coverage through an exchange?

26. How will it affect me? • When do I have to start thinking about this? • Am I ever exempt, especially between jobs? • Can I stay in the same provider network? • How does this address my family’s coverage? • How portable is this new coverage? • What’s the penalty? • How much will it cost? • What about premium cost growth? • How do benefits compare to current coverage? • How do I get coverage and how does this affect benefit choices? • What kind of coverage do I need based upon my current health status age, location, and lifestyle?

27. Age 35-55: Advantages • If you are currently covered process may be transparent • Improved affordability compared to current system? • Subsidies and premium tax credits based upon income level • Catastrophic coverage • Debt and asset protection • Bankruptcy avoidance

28. Age 55-65: Considerations • Nationally, 4.3 million people in this age group were uninsured in 2008. That is probably higher now • Currently, this group may be too old to afford insurance in the individual market. The exchange and guarantee issue provide better opportunities for coverage • This group will be the highest users of health care across the 3 groups • This group has the highest incident of chronic illness. • Health coverage will be a high priority • Provider network concerns will be especially important

29. Age 55-65: Considerations (cont) • This group is the most likely to have insurance coverage already, assuming that they can afford it • This group may be the most likely to have premium increases • This group will be the least likely to choose paying a penalty over coverage. • This group will be familiar with health insurance concepts and terminology • This higher age range of this group will be looking to bridge the gap to Medicare • This group may have a declining income • This group is likely to have a less stable employment status over time

30. Age 55-65: Outreach Tools • Insurance industry and organizational marketing. (Note: this will be the single most important outreach mechanism. We need to work closely with and learn approaches from carriers). • Brokers, insurance agents and navigators • Organizations like AARP • PSAs, Web ads, Web sites, Printed media • Call centers and (robo-calls?) • Faith-based groups and churches • Businesses, business groups and HR managers • Financial consultants and advisors

31. How will it affect me if…? • I’m unemployed or employment is part time • I’m employed and my employer provides affordable coverage • I’m employed but coverage is not affordable? • I’m employed but my employer does not offer coverage or dropped coverage • I’m self-employed • I’m considering early retirement • I’m at risk of lay off or declining salary

32. How will it affect me? • How does this help me get coverage if I don’t’ have it or currently can’t afford it? • How does this help me if I get laid off or retire early? • How does this help me in the time gap before qualifying for Medicare, especially if age qualifications for Medicare increase or if benefits are means tested? • Should I think about this coverage as supplemental insurance (Medigap) when I do qualify for Medicare? • When do I have to start thinking about this? • Am I ever exempt, especially between jobs? • Can I stay in the same provider network? • How portable is this coverage? • What’s the penalty? • How much will coverage cost? • What about premium cost growth especially due to changes in health status or usage? • How do benefits compare to current coverage? • How do I get coverage and how does this affect benefit choices? • What kind of coverage do I need based upon my current health status, age, location, and lifestyle?

33. Age 55-65: Advantages • Improved affordability compared to current system (?) • Better stop gap options prior to Medicare • Makes individual market coverage more certain and possibly more affordable • Subsidies and premium tax credits based upon income level • Catastrophic coverage • Bankruptcy protection • Debt and asset protection

34. Identify exemptions to the Individual Mandate (Responsibility) provisions • Financial hardship • Those without coverage for less than three months • If the lowest cost coverage option exceeds 8% of an individual’s income • Individuals with incomes below the tax filing threshold (in 2009 the threshold for taxpayers under age 65 was $9,350 for singles and $18,700 for couples). • Religious objections • American Indians • Undocumented immigrants • Incarcerated individuals

35. Tax Penalty • Specific Tax Penalty: • The greater of $695 per year up to a maximum of three times that amount ($2,085) per family or 2.5% of household income. • Penalty Phase-in • 2014: $95 per person (capped at $285 per family) or 1 percent of household income • 2015: $325 (capped at $975) or 2 percent of household income • 2016: $695 (capped at $2,085) or 2.5 percent of household income • 2017 and after: The $695 penalty is indexed for a cost-of-living adjustment and must be rounded to the next lowest multiple of $50. For families, the flat-dollar penalty is capped at three times the indexed value for an individual. For example, if in 2017 the penalty is $700, the capped amount would be $2,100. As in 2016, the individual mandate penalty is the greater of the flat-dollar amount or 2.5 percent of household income • Describe how the penalty will be assessed and indicate that violators are not subject to prosecution for tax evasion.

36. Highlight and define key terms and concepts (leave take home handouts or websites for these concepts and terms, FAQs, etc.): • Specific terms such as: Premium subsidies, Premium tax credits, Cost sharing, Co-pays Deductibles, FPL, ESI, etc. • General concepts such as: Individual, Small group, Large group insurance markets, Guarantee issue, pre-existing conditions, etc.

37. How to obtain insurance if… • If employed • If unemployed • If self-Insured Purchasing options inside and outside of the exchange (Note: the real question here is what the heck is an exchange and how do I use it? Also how can I get help using it?)

38. Coverage Options for: • Dependent coverage through age 26 • Essential benefits package • The heavy metal benefit tiers including catastrophic coverage • Maintenance coverage vs. catastrophic coverage

39. Premium Credits and Cost Sharing: Eligibility • Individuals and families with incomes between 133-400% FPL to purchase insurance through the Exchanges. • Limited to U.S. citizens who meet income limits • Employees who are offered coverage by an employer are eligible for premium credits if: • Employee share of the premium exceeds 9.5% of income. • Employer plan does not have an actuarial value of at least 60% • Legal immigrants who are barred from enrolling in Medicaid during their first five years in the U.S.

40. Premium Credits and Cost Sharing: Credit levels • Tied to the second lowest cost silver plan in the area • Up to 133% FPL: 2% of income • 133-150% FPL: 3 – 4% of income • 150-200% FPL: 4 – 6.3% of income • 200-250% FPL: 6.3 – 8.05% of income • 250-300% FPL: 8.05 – 9.5% of income • 300-400% FPL: 9.5% of income

41. Cost Sharing Subsidies • 100-150% FPL: 94% • 150-200% FPL: 87% • 200-250% FPL: 73% • 250-400% FPL: 70%

42. Facilitator: Susan Downs-Karkos Race, Ethnicity,Language, Culture

43. Data Needs • It would be helpful if other data dimensions that are collected, such as around income, employment status, etc. are also broken down by race/ethnicity • How are different ethnic groups receiving health care and insurance today? • Information on immigration status - for instance, legal immigrants who may have been here less than five years, will not qualify for public benefits, but can purchase in the exchange and receive subsidies.  Who are they?

44. Messaging • How do the messages that are being developed for the mainstream resonate with these subgroups?  We anticipate that many messages around cost, for instance, may not be as effective with these groups. • Emphasizing doing what is best for your kids and taking care of your family are messages that will work • Need to create a trust.  (Also need to verify that Department of Homeland Security won't have access to this data.  If they do, then the undocumented parents of citizen children are not going to enroll their kids.) • Emphasize that you have all materials/communication available in Spanish • Messages that include that those with linguistic and cultural differences are welcomed to join the HIE, those differences are honored and that there is interpretation available • Emphasize ease of use - there is a clear, user-friendly, non-cumbersome way to get services

45. Outreach • Navigators who are of the same cultural/linguistic background of those targeted for enrollment in HIE.   • They can work through churches, cbos and others to engage with the population and help them navigate the coverage process.  They have the trust of the population.   • The exchange should provide grants for this purpose.   • Choice Administrators is developing I-Pad technology to help people like navigators enroll diverse participants in HIE-like programs. • Find a core group of people from a particular racial/ethnic/linguistic background who would be eligible.  Work within that group and expand it outwards. • Develop simple, one-page FAQs that could be translated into a variety of languages and used by navigators with diverse populations. • Remember that often the staff themselves of cbo's may qualify - they themselves are a target audience.

46. Facilitator: Joe Campe Gender and Family

47. Data Needs • Are women insured under Medicaid at higher rates? • Marital status? • Education level? • Children vs. no-child? • Where are the subgroups currently?

48. Messaging • Women think their child’s health is more important –the children need sports/school physical and women may be more likely to take care of those needs • Young invincible response is different based on gender • Confounded with age, gender, family, marital status  Subgroups: Men and women by age, Student status, Marital Status, Education, Children vs. no-child, Exchange vs. Medicaid coverage, Health status (chronic disease vs. not, disability)

49. Subgroups • Young invincible are still important for gender, determining how to get to young invincible based on gender • Preventative health may change what women think

50. Facilitator: Joel Rosenblum Geography and distribution channels