Transcript Children’s Benefits inCharting the Way: Progress and Priorities for Child and Family Coverage July 19, 2012

Children’s Benefits in
2014
Charting the Way: Progress and Priorities
for Child and Family Coverage
July 19, 2012
EHB Background
o Non-group and small group market
plans, in and out of exchanges
o 4+ million children; 8+ million parents
o Also newly-eligible Medicaid enrollees
o Under ACA, the Secretary of HHS
“shall define” EHBs
o Secretary has determined that each
state will select its EHBs by choosing
a benchmark plan
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EHB Process
End of Third Quarter
2012
o Up to 10 plans are choices for
each state
o State chooses plan, all
benefits and limits become
the EHB package
o If missing one of 10 ACA
categories, must supplement
with another choice
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Where Do States Stand?
http://www.statereforum.org/state-progress-on-essential-healthbenefits
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The 10 ACA Categories
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What Are Pediatric Services?
o Many services included in
other categories
o Services to watch—
mentioned explicitly in 10
categories
o Pediatric dental and vision
o Habilitation
o Maternity care for
dependents
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What Are Pediatric Services?
o Others not explicitly
mentioned in 10
categories
o Hearing care,
including
screenings,
treatment, and
hardware
o Weight control
services
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Engaging on EHB
• Work with providers
and disease-specific
allies
• Ask for full details on
plan benefits and limits
• Push for supplementing
benefits when
necessary
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Comparison of Covered Benefits—
What about Limits?
EXHIBIT 1
MICHIGAN ESSENTIAL HEALTH BENEFITS COMPARISON*
Benefits provided by potential benchmark major medical plans - data as of 3/31/12
Grouped in the 10 categories of Essential Health Benefits required by the ACA.
See http://www.healthcare.gov/news/factsheets/2011/12/essential-health-benefits12162011a.html
Terms:
MB - Michigan mandated benefit
Benefits [3]
BCBSM
Community
Blue
PPO Plan 4
1. Ambulatory patient services - Federal Mandate
Primary Care Visit to Treat an Injury or
Yes
Illness
Specialist Visit
Other Practitioner Office Visit
(Nurse, Physician Assistant)
Outpatient Surgery
Physician/Surgical Services
Outpatient Facility Fee
(e.g., Ambulatory Surgery Center)
Yes
Small Group
HMO
Priority
Health
(HMO)
BCN10
(HMO)
Priority
Health
(HMO)
BCBSM
(Self-insured)
Yes
Yes
Yes
Yes
Yes
must be
must be
participating
participating
Yes
provider
provider
referral
A nonA nonrequired except
participating
participating
OB/GYN
provider
provider
requires prior
requires prior
approval
approval
State Employee Plans
PHP
(HMO)
FEHBP
BCBSM
Standard
Option
FEHBP BCBS
Basic Option
FEHB GEHA
Standard
Option
Michigan
Mandate
Yes
Yes
Yes
Yes
Yes
Yes
MB
500.3519(3)
Yes
Yes
Yes
Yes
Yes
Yes
MB
500.3519(3)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
MB
500.3519(3)
Yes
Yes
Yes
Yes
MB
500.3406c
550.1417
Doesn't
specifically
include or
exclude this
benefit
Doesn't
specifically
include or
exclude this
benefit
MB
500.3406d
550.1416
Yes
Yes
MB
500.3406k
500.3519(3)
550.1418
Home Health Care Services
Yes
Yes
Yes
Yes
Yes
Yes
limited to 60
visits per
calendar year
Hospice Care
Yes
Yes
maximum of 45
days per
contract year
Yes
Yes
maximum of 45
days per
contract year
Yes
Yes
Breast Cancer Outpatient Treatment
Services
Federal Employee Plans
Priority
Health
(HMO)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Doesn't
specifically
include or
exclude this
benefit
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
2. Emergency Services - Federal Mandate
Emergency Room Services
5/21/2012
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Supplementing Benefits
• Supplements must
come from another
benchmark option
• Who decides that
supplementation is
necessary?
– i.e. What to do with a
half full bucket?
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