Vermont Health Insurance Benefits: Essential Health Benefits Analysis, Part II

The Vermont Exchange Advisory Group

February 27, 2012

2

Agenda

Review of EHB / Requests

Prior Authorization

Missing Services in Categories Required by the ACA

Update on Benefit Restrictions

Standardized Summary of Benefits

Requests for Additional Information

At the last Exchange Advisory Committee Meeting and the Green Mountain Care Board Meeting, requests were made for more information about:

Benefits Restrictions Prior Authorization Options for supplementing plans when categories are

missing

Since then, we have also received additional guidance from HHS

4

EHB will be defined by a benchmark plan selected by each state.

HHS Update: The benchmark chosen in 2012 will apply for both years 2014 and 2015.

The plans offered in the state must be “substantially equal” to the benchmark plan.

Reviewing EHB: Use of a Benchmark Plan

Reviewing the EHB Options:

Potential Options in Vermont:– Largest small group plans

• MVP – Preferred exclusive provider plan (CY11 Q4: 7,414)• BCBSVT – BlueCare (estimate for CY12 Q1: 7,201)

– Largest HMO• BCBSVT (~31,000 enrolled; benefits are generally the same as

in small group)

– State employee plan (administered by Cigna)

Did not consider the federal employee health benefits plan

HHS Update: plans to provide States with a list of the top three small group market products in each State based on data from HealthCare.gov from the first quarter of the 2012 calendar year.

6

Agenda

Review of EHB / Requests

Prior Authorization

Missing Services in Categories Required by the ACA

Update on Benefit Restrictions

Standardized Summary of Benefits

Update on Benefit Restrictions

Under the intended approach, a plan must be substantially equal to the benchmark plan, in both the scope of benefits offered and any limitations on those benefits such as visit limits.

A plan could substitute coverage of services within each of the ten statutory categories, so long as substitutions were actuarially equivalent.

HHS Update: Process for Determining Equivalence

Relies on an actuarial report that: Uses a standardized set of utilization and price factors

and population; Applies the same principles and factors in comparing the

value of different coverage; Does not take into account any differences in coverage

based on the method of delivery or means of cost control or utilization used; and

Takes into account the ability of a plan to reduce benefits by considering the increase in actuarial value of health benefits coverage offered that results from the limitations on cost sharing (with the exception of premiums) under that coverage.

The overall amount of restrictions is important, the specific details are not

The specific types of restrictions matter less than the overall amount of restrictions because the plans have the flexibility to change the specific restrictions (add some new ones and remove others entirely) as long as they maintain actuarial equivalence.

Example from HHS: A plan could offer coverage consistent with a benchmark plan offering up to 20 covered physical therapy visits and 10 covered occupational therapy visits by replacing them with up to 10 covered physical therapy visits and up to 20 covered occupational therapy visits, assuming actuarial equivalence and the other criteria are met.

10

Agenda

Review of EHB / Requests

Prior Authorization

Missing Services in Categories Required by the ACA

Update on Benefit Restrictions

Standardized Summary of Benefits

Prior Authorization

See handout

12

Agenda

Review of EHB / Requests

Prior Authorization

Missing Services in Categories Required by the ACA

Update on Benefit Restrictions

Standardized Summary of Benefits

13

Ambulatory patient services

Emergency services Hospitalization Maternity and newborn

care Mental health and

substance use disorder services, including behavioral health treatment

Prescription drugs Rehabilitative and

habilitative services and chronic disease management

Laboratory services Preventive and

wellness services Pediatric services,

including oral and vision care

ACA Requires That EHB Include Services Within 10 Categories

Missing Services

If benchmark plan does not include coverage for all 10 categories, state must supplement the missing categories with the benefits from another benchmark option – habilitative services– pediatric oral – pediatric vision– prescription drugs

HHS Update: HHS intends to propose that if benefits in a statutory category are offered only through the purchase of riders in a benchmark plan, that required EHB category would need to be supplemented by reference to another benchmark plan option

The plan selected will determine which “Missing” services you need to fill

Categories MVP BCBSVT State Plan

Habilitative Services

Pediatric VisionLimited benefits

IncludedLimited benefits

Included

Pediatric Oral

Prescription Drugs

Included (no choice)

Habilitative Services: No Separate Decision Required

Update from HHS: HHS will either:

– Require plans to offer the same services for habilitative needs as it offers for rehabilitative needs and offer them at parity.

Or – A plan would decide which habilitative services to cover and

report the coverage to HHS. HHS would evaluate and further define habilitative services in the future. Under either approach, a plan would be required to offer at least some habilitative benefit.

Defining Habilitative Services: MVP

MVP’s Definition: focus exclusively on medical benefits and not expand

medical benefits to include social or educational services traditionally not covered  by health insurance.  These medical services could include physical therapy, occupational therapy and speech therapy, as examples of "medical" habilitative services. 

Also utilize reasonable service limitations (such as visit limits), medical management tools and requirements regarding provider licensure.

Defining Habilitative Services: BCBSVT

BCBSVT’s Definition: Rehabilitative services are health services intended

to relieve pain, restore physical function, or improve psychological function where pain or functional impairments result from disease, injury or loss of body part.

Habilitative services are health services that aim to achieve physical or psychological function impaired by congenital or developmental conditions that prevent normal function, whether normal function was initially present or not.

Defining Habilitative Services: State Plan

The state plan does not currently cover habilitative services and was unable to provide us with a proposed definition of habilitative services.

Vision Care in the Plans

Services BCBSVT State Plan

Routine Vision Exam (Refraction) One annual exam

$100 to use towards vision services every

24 months*

Eyeglasses and Contact Lenses

May use the $100 towards lenses*

Replacement of eyeglasses or contact lenses, in whole or in part

Frames

*since dollar limits are not allowed under the ACA, benefit with dollar limits will be incorporated into the EHB definition without the dollar limit.

Unclear whether they provide enough coverage to “count” as services within the category

Pediatric Vision Care: No Separate Decision Required

If the plans are “missing” pediatric vision care, HHS is considering proposing that the State would supplement the plan with the benefits covered in the FEDVIP vision plan with the highest enrollment.

Pediatric Oral Care: Decision will be Required

All of the plans are missing services in the Pediatric Oral care category.

HHS is considering proposing that the State would supplement the benchmark plan with benefits from either:

– The Federal Employees Dental and Vision Insurance Program (FEDVIP) dental plan with the largest national enrollment; or

– The State’s separate Children’s Health Insurance Program (CHIP).

Prescription Drugs: Decision will be Required State Options:

– State Employee Plan – Federal Employees Health Benefits Plan

If a benchmark plan offers one drug in a certain category or class then all the plans in the small group and individual market must cover at least one drug in that category or class

The drug category and class lists will be provided by the U.S. pharmacopoeia, AHMS or other standard. (not available yet)

Recommend waiting for further direction from HHS regarding the classes and categories before conducting the comparison

24

Agenda

Review of EHB / Requests

Prior Authorization

Missing Services in Categories Required by the ACA

Update on Benefit Restrictions

Standardized Summary of Benefits

ACA Requires Standardized Summary of Health Insurance Benefits

CCIIO released two forms on February 9, 2012– Drafted with assistance of National Association of Insurance

Commissioners (NAIC)

Summary of Benefits– Includes information on cost-sharing– Includes information by category of service

• In/out of network providers• Service limitations

Uniform Glossary of Benefits– Standard definitions for common health coverage terms

• Examples: co-insurance, emergency room care, balance billing