Transcript Document

Essential Health Benefits:
Getting Specific, Getting Prepared
Christopher F. Koller
Health Insurance Commissioner, State of RI
NASHP Annual Meeting
October 3, 2011
Agenda
• What does ACA say about EHB’s?
• Let’s set a baseline
– Populations directly affected by EHB definition
– Some definitions
• Lessons from IOM Committee
• Timelines
• Implications for States: Our Speakers
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EHB’s in Affordable Care Act
• Intent: Answer the question – What
constitutes the health insurance every
one is to buy in ACA?
• Relevant Section: 1302
• EHB’s are “to be defined by Secretary of
HHS”
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EHB’s in Affordable Care Act
The Statutory Guidance Conflict in 1302:
“At least the following categories
and the items and services
covered with in
1.Ambulatory Patient Services
2.Emergency Services
3.Hospitalization
4.Maternity and newborn care
5.Mental Health and Substance
Abuse Disorder Services
6.Prescription Drugs
7.Rehabilitative and habilitative
services and devices
8.Laboratory Services
9.Preventive and wellness
services and chronic disease
management
10.Pediatric Services, including
oral and vision care”
vs
“The Secretary shall ensure that
the scope of essential health
benefits ..is equal to the scope of
benefits under a typical employer
plan as determined by the
Secretary”
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EHB’s in Affordable Care Act
“Required Elements for Consideration”
(in Section 1302)
• Appropriate balance between categories
• Non discrimination in design and administration of benefits
based on age, disability or life expectancy
• Take into account healthcare needs of diverse segments of
population
• Ensure the EHB’s are not denied based age, length of life,
present or predicted disability, degree of medical dependency,
or quality of life
• Must cover emergency treatment in and out of network
• (dental plans and full health plans)
• Periodic reviews, reports and updates
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EHB’s in Affordable Care Act
Statutory Strategy
• “The Secretary shall…”
• Strategic vagueness and principles (that
appear to conflict in places)
• Contrast this to negotiating a list in statute
(Clinton reform strategy)
• In hindsight – a little bit of structure and
process in statute would have been helpful…
– Federalism?
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EHB’s: What populations are directly
affected by this determination?
Inside the Exchange
Outside the Exchange
Individual Market
Yes
Yes
Small Group Market
Yes
Yes
Large Group and Self
Insured
(N/a)
No
Medicaid
Only Medicaid Benchmark Plans
Basic Health Plans
Yes
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EHB’s: the floor or the room?
• Employers may always choose to cover more
than the EHB package
• But the federal government will only subsidize
insurance in the Exchange at the EHB level; and
• The state is fully responsible for the costs of
benefits in the Exchange beyond the EHB level
for subsidy recipients
• Implications
– great pressure on state mandates not in EHB
package
- Significant influence in EHB definition on market
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“What’s Covered”:
Getting the Language Straight
“Covered
Services”
“Benefit Design”
“Benefit
Administration”
What is it
The list of services to Terms and conditions of
be paid for
coverage
How those terms and conditions
are administered
Examples
Usually broad and
vague inclusions and
very specific
exclusions
Medical Necessity
Cost sharing
Visit Limits
Network limitations
Prior Authorization
Claims Payment rules
Plan Policies and Procedures
Medical Management guidelines
Medical Necessity
determination
Public
Oversight
Examples
EHB definition
State Mandates
MH Parity
Medicare and
Medicaid
State law – coverage
minimums
Federal law – “Precious metals”,
external appeals
Public Contracts
Exchange terms
State Law – UR certification
Internal Appeals, prompt
payment
Federal Law – External appeals
Industry standards - NCQA
ACA
“opportunity”
Standardized,
rational, sustainable
definitions through
EHB process
Standardized oversight through
exchanges and Medicaid
managed care
QHP certification in exchanges.
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Institutes of Medicine EHB Committee
• Charge from Assistant Secretary for Planning
and Evaluation for HHS:
– Recommend to the secretary a process for
determining EHB’s
– How to take into account “required elements for
consideration”
– Thoughts on medical necessity
– Take in public comment on defining and updating
EHB’s
• Composition
– State officials, industry, academia, providers,
consumers
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IOM Committee: Issues in Defining EHB –
from public comment process
1. Balancing generosity and affordability: base line package and
changes over time
2. Defining a “typical” employer.
3. Evaluating state mandates
4. Considering specificity and flexibility in EHB guidance.
5. Determining medical necessity
6. Applying evidence and encouraging innovation (in benefit
coverage, design and administration)
7. Protecting patients – applying “required elements”
8. Ensuring fair processes—public engagement, independence of
decision makers, and transparency of information used when
making benefit decisions were all considered fundamental.
http://www.iom.edu/Reports/2011/Perspectives-on-Essential-Health-Benefits-Workshop-Report.aspx
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EHB Milestones
• Very soon: IOM report to Secretary
• Secretary gives draft guidance to states and exchanges
• States have to implement
– Commercial Market/ Statutory mandates (2012 legislative
session?)
– Medicaid Programs
– Exchange Programs (as needed)
– Stakeholder education
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Remainder of Session
• Perspectives for States:
–Medicaid Programs
–Commercial Markets
–Sustainability and Coordination across
Covered Populations
“States should count on a lot of
terrifically hard and terribly important
work.”
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