nhc essential health benefits recommendations

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A United Patient Voice on Essential Health Benefits Marc Boutin Executive Vice President & COO National Health Council August 3, 2011

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The National Health Council conducted research, did an analysis, and prepared proposed regulatory language to assist the Secretary of Health and Human Services with the preparation of an essential health benefits (EHB) package that will serve the needs of people with chronic diseases and disabilities. This slide show is from a NHC briefing on EHB, given August 3, 2011.

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Page 1: NHC Essential Health Benefits Recommendations

A United Patient Voice onEssential Health Benefits

Marc BoutinExecutive Vice President & COO

National Health Council

August 3, 2011

Page 2: NHC Essential Health Benefits Recommendations

© National Health Council

The mission of the National Health Council is to provide a united voice for people with chronic diseases and disabilities.

Page 3: NHC Essential Health Benefits Recommendations

© National Health Council

Potential Approaches to Developing the Essential Health Benefits Package

1 2 3

Define benefits narrowly

Medicare Part B program

Define categories of benefits broadly and establish process-oriented requirements as a ‘check’ on plans

Medicare Part D program

Define categories of benefits broadly, granting plans the flexibility to develop coverage policies within each category

FEHBP plan

Page 4: NHC Essential Health Benefits Recommendations

© National Health Council

Essential Health Benefits Landscape

IOM DOL HHS+ State Exchanges

Health Plans

Informing Regulations Developing Regulations Implementing Regulations

Promote robust, transparent oversight process at the federal and state levels

Develop a more granular understanding of the services that are considered essential and the cost impact of those services

Continue to endorse NHC’s values on EHB

Ensure that any limitations to DOL’s database are addressed

Page 5: NHC Essential Health Benefits Recommendations

© National Health Council

Timeline for Engagements: Essential Health Benefits

March 2011 May July September November January 2012

Proposed Rule Anticipated from HHS

IOM Committee Meeting

IOM Recommendations Expected

DOL data expected in “Spring”

Third and fourth IOM Committee meetings

Develop essential health benefits package using FEHB plan as foundation in consultation with NHC members

Develop ideal approach for HHS/State regulatory oversight

Vet regulatory approaches with NHC members

Share regulatory approach with HHS

Commission actuarial analysis of the affordability of NHC’s essential health benefits package and discuss implications among membership

Craft regulatory language that HHS could adopt and review with NHC membership

Craft regulatory language

Page 6: NHC Essential Health Benefits Recommendations

© National Health Council

Development of Policy Recommendations

EHB White Paper

• This report established baseline knowledge and considered the approaches HHS may take in defining the EHB package

EHB Cost Analysis

• This analysis examined the cost of a comprehensive health benefits package, using the Federal Employees Health Benefits Package as a model

EHB Policy Recommendations

• This report will articulate NHC’s recommendations and proposed solutions and will be shared with key policymakers and stakeholders

Page 7: NHC Essential Health Benefits Recommendations

© National Health Council

Regulatory Opportunities

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© National Health Council

Non-Discriminatory Utilization Management

Recommendation HHS Regulatory Opportunity

EHB regulation should provide for oversight of plan benefit design to avoid discrimination caused by unfair utilization management techniques

Outline oversight mechanisms for states to use in reviewing plan utilization management policies

States should establish oversight mechanisms to review plan processes

HHS should continue to monitor state oversight programs to guarantee that plans are meeting federal requirements

MODEL PROGRAM: The Medicare Part D Formulary Review process analyzes the use of practices such as prior authorization, step therapy, and quantity limits and compares practices to industry standards, guidelines, and other Part D plans.

Page 9: NHC Essential Health Benefits Recommendations

© National Health Council

Continuity of Care Protections

Recommendation HHS Regulatory Opportunity

EHB regulation should include patient protections to ensure plan cooperation and coordination when people switch enrollment between plans

Include protections for patients switching enrollment (among qualified health plans and to and from Medicaid) so patients do not have to re-establish the necessity of treatment protocols already in place

Require plans to provide written notice of the right to transfer treatment protocols

Require Navigator education programs to provide information about the potential implications of switching between plans

MODEL PROGRAM: Medicare Part D Auto and Facilitated Enrollment processes ensure beneficiaries with limited income remain enrolled in Part D plans that have reduced costs.

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© National Health Council

Cost-Sharing Protections

Recommendation HHS Regulatory Opportunity

EHB regulation should require plans to have non-discriminatory cost-sharing policies across benefit categories.

Exchanges should allow creative benefit design to encourage plans to develop novel approaches to cost- sharing

Require plans to disclose the deductible, co-payment, and co-insurance amounts applicable to covered services prior to enrollment

Prohibit specialty tiers

Offer protection from high out-of-pocket costs on prescription drugs and allow tiering exceptions

Create oversight mechanisms to ensure that states are reviewing plan benefit design to ensure cost-sharing is neither unfair nor discriminatory

MODEL PROGRAM: The Maryland Comprehensive Standard Health Benefit Plan* specifies cost-sharing requirements for certain services and includes some service limits to offer an extra level of patient protection for enrollees in these plans.

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© National Health Council

State Navigator Programs

Recommendation HHS Regulatory Opportunity

EHB regulation should contain specific mechanisms to assist patients in identifying an appropriate plan and navigating enrollment and other key plan processes

Include resources to educate enrollees about their plan rights and responsibilities

Prohibit educational materials and programs from steering or attempting to steer people into a plan or type of plan

Navigator programs should coordinate with other consumer assistance programs in the state

MODEL PROGRAM: The State Health Insurance Assistance Programs (SHIPs) are an often cited example of what a Navigator program could resemble. SHIPs provide assistance to Medicare beneficiaries and help them with their Medicare benefits.

Page 12: NHC Essential Health Benefits Recommendations

© National Health Council

Plan Premium Costs

PlanEstimated

Annual Premium—Individual*

OOP Maximums Total Cost

BCBS Model $5,032

Platinum $5,205 $1,500 $6,705

Gold $4,627 $5,950 $10,577

Silver $4,048 $5,950 $9,998

Bronze $3,470 $5,950 $9,420

*The estimated premiums and the reduced OOP max for the platinum plan are actuarial estimates from ARC.

Page 13: NHC Essential Health Benefits Recommendations

© National Health Council

Care Coordination & Management Activities

Recommendation HHS Regulatory Opportunity

EHB regulation should require proven effective care coordination and management activities to improve outcomes and reduce total healthcare costs

Require care coordination activities as an essential health benefit

Create pathways for plans to develop innovative strategies to compensate providers for effective care coordination

Encourage state IT programs to include information about the care coordination policies of plans on state Exchange websites

MODEL PROGRAM: Medicare Advantage coordinated care plans are required to have quality improvement and chronic care improvement programs as well as monitor and evaluate these activities and outcomes.

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© National Health Council

Medical Necessity Decision Making & Appeals ProcessesRecommendation HHS Regulatory Opportunity

EHB regulation should outline clear, understandable standards for plan medical necessity determinations and should include a process for appealing adverse plan determinations

Require plans to use medical necessity criteria that are objective, clinically valid, and compatible with generally accepted principles of care

Plan denials based on lack of medical necessity should explain, in clear language, the criteria used to make the determination

Create uniform exceptions and appeals process for items and services that do not meet definition of medical necessity

Navigator programs should be available to guide patients through the complexities of plan appeal processes

MODEL PROGRAM: Medicare Part D offers an example of a federally regulated, nationwide program that has set requirements of participating plans for exceptions and appeals processes.

Page 15: NHC Essential Health Benefits Recommendations

© National Health Council

State Exchange Requirements

Recommendation HHS Regulatory Opportunity

HHS Exchange regulation should include federal and state oversight to ensure that plans offered on state exchanges meet all appropriate and necessary criteria (including network adequacy standards)

Require Exchanges to monitor and seek to improve quality of care

Plans may not exclude eligible individuals from coverage

Plans utilizing a provider network shall be required to demonstrate an adequate number of in-network providers in various specialties corresponding to the EHB categories of services

MODEL PROGRAM: The Massachusetts Health Connector’s Commonwealth Choice program offers a variety of plans with different benefit packages. The Health Connector reviews and approves each plan offered in Commonwealth Choice. Of the two operational health insurance exchanges (MA and UT), the program in Massachusetts provides more oversight and patient protections than the exchange in Utah.

Page 16: NHC Essential Health Benefits Recommendations

© National Health Council

Regulatory Opportunities

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Marc BoutinExecutive Vice President & COO

National Health [email protected]