Essential Health Benefits and QHP Selection Process Recommendations

1
Essential Health Benefits and QHP Selection
Process Recommendations

• Health Care Commission
• September 6, 2012

www.pcghealth.com
2
Agenda

• Governance Model Revision
• Update Exchange Timeline through January 2014
• Essential Health Benefits Benchmark
  Recommendation
• QHP Selection Process Recommendation

3
Governance Model Revision

• In late 2011, the Federal government released new
  options for States to consider in establishing a
  Health Benefit Exchange (Exchange)
• These new options, as clarified through federal
  rule making, allowed States to enter into a
  partnership with the Federal government.
• States in a partnership could choose to retain
  Plan Management functions, Consumer Assistance
  functions, or both. The Federal government would
  administer all other functionality, most notably
  the large technical infrastructure to support
  Exchange operations.
• Prior to the release of these new options, the
  Health Care Commission carried a motion to
  recommend a State-based Exchange for Delaware.
• At the time of this vote, the alternatives were
  to cede all functionality to the
  Federally-Facilitated Exchange or find other
  States with which to create a regional Exchange.
• Of these options, the most viable choice was to
  pursue a State-based model
• Following the release of the Partnership model,
  DE re-assessed the financial viability of all
  available options and determined that the
  State-Federal Partnership is the most appropriate
  choice.

4
Update Exchange Timeline

• September 2012
• Final recommendation on Essential Health Benefits
  benchmark submitted to HHS
• Final recommendation on Qualified Health Plan
  (QHP) selection process
• October 2012
• Final recommendations on all QHP policies,
  including certification criteria and other
  standards related to plan management
  functionality
• Final recommendations for Navigator and In-Person
  Consumer Assisters certification criteria and
  phased approach to Outreach and Education
• Continue activities to engage Consumer Assistance
  and Outreach partners in planning process
• November 2012
• Finalize draft QHP process, rating criteria, and
  certification application
• Finalize readiness checklists and training
  materials for Navigators and In-Person Assisters
• Submit Declaration Letter confirming Exchange
  model to HHS

5
Update Exchange Timeline

• December 2012
• Exchange readiness review conducted by Federal
  government
• January 2013 March 2013
• Exchange readiness complete.
• State moves forward with operational
  implementation of plan management and consumer
  assistance functionality
• March 2013
• Begin accepting QHP applications
• April 2013 October 2013
• Launch full outreach and education campaign in
  preparation for open enrollment
• October 2013
• Open enrollment begins for QHP plans through the
  Exchange
• January 2014
• Plan coverage year commences

6
Essential Health Benefits

• The Affordable Care Act requires that any health
  insurance plan offered to an individual or small
  business must meet certain standards.
• These standards, known as essential health
  benefits, must cover the ten broad categories of
  services listed below.
• This list applies to health insurance plans
  offered inside and outside of the Exchange and
  represents the minimum services that must be
  covered. Health insurance plans may cover
  additional services at their own discretion.
• Essential Health Benefit (EHB) Service Categories
• 1. Ambulatory patient services
• 2. Emergency services
• 3. Hospitalization
• 4. Maternity and newborn care
• 5. Mental health and substance use disorder
  services, including behavioral health treatment
• 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

7
Essential Health Benefits

• The State has the option to choose an Essential
  Health Benefits benchmark from among several
  options
• The three largest small group insurance products
  in Delaware
• Blue Cross Blue Shield (BCBS) Exclusive Provider
  Organization (EPO)
• Blue Cross Blue Shield (BCBS) Health Maintenance
  Organization (HMO)
• Coventry Point of Service (POS)
• The three largest state employee health benefit
  plans in Delaware
• Comprehensive Preferred Provider Organization
  (PPO)
• HMO
• Consumer Directed Health (CDH) Gold
• The three largest federal employee health benefit
  plans
• Blue Cross/Blue Shield FEHP Standard Option
• Blue Cross/Blue Shield FEHP Basic Option
• Government Employees Health Association (GEHA)
  Plan
• The BCBS Small Group EPO plan currently has the
  largest enrollment of the small group options

8
Essential Health Benefits

• To support this decision, the State conducted the
  following stakeholder data collection process
• Posted analysis of benchmark options along with
  supporting background material to the HCC website
  and issued press releases and email blasts to
  spread awareness of the process
• 45 day public comment period started in June
• 2 public forums hosted in Dover to answer
  questions and discuss options
• 54 attendees total for the two forums
• Received 45 written comments through the HBE
  Inbox and the Health Care Commission during the
  comment period
• Comments received through this process are
  summarized on the following slides by category

9
Essential Health Benefits

• Cost, Affordability, and Design
• Inclusion of only those benefits traditionally
  identified as necessary to compromise a group
  market-accepted program. Benefits other than
  those mandated by DE law, and those not included
  in most common DE employers plans should not be
  included.
• Inclusion of quantitative limits (visit/day
  limits/per procedure limits) wherever appropriate
• Additional benefits should utilize treatment
  limitations to maintain affordability
• Plan should not have excessive cost-sharing
  requirements to protect consumers from unexpected
  financial obligations
• Allow maximum flexibility regarding actuarially
  equivalent substitutions within benefit
  categories, and provide clarity indicating how
  and under what circumstances substitutions may be
  made
• Ensure that plans do not utilize benefit design
  flexibility to discriminate against vulnerable,
  high-cost consumers
• Allow flexibility in plan design and permit
  substitutions, continue to allow insurers to use
  appropriate care management and health promotion
  tools
• Work with insurers to manage the product and rate
  filing process
• Consistency in design through 2015
• Establish clear and meaningful standards for
  comparing QHPs to the benchmark plan

10
Essential Health Benefits

• Chronic Disease
• Cancer
• Access to oral and IV administered chemotherapy,
  stem cell transplant and radiation therapy.
• Equal treatment of patients receiving IV,
  injectable, and/or orally administered treatments
• Coverage for treatment at National Cancer
  Institute (NCI) cancer centers
• Prescription drug benefit that offers full
  coverage of 6 protected classes (gt1 per class)
• Balanced coverage and affordable access for all
  aspects of cancer treatment preventive care to
  diagnostic tests to treatment options (targeted
  therapies, palliative care, hospice)
• Monitor the use of tiered networks that may
  discriminate against specialty drug needs
• Breast cancer screenings for women and men
• Multiple Sclerosis
• Access to inpatient hospital services without
  caps for people with chronic illnesses
• Protections from discrimination against specialty
  medications placed on a fourth, or specialty tier
  with different cost-share structure
• Allow for the number of physical therapy visits
  to be determined by physical therapist or
  patients doctor, rather than having a
  predetermined limit

11
Essential Health Benefits

• Chronic Disease cont.
• Hemophilia
• Access to specialists at federally recognized
  hemophilia treatment centers (HTCs)
• Access to full range of FDA approved clotting
  factor products
• Access to range of specialty pharmacy providers
• Medical necessity should not be defined by
  insurers, but determined by physicians in
  conjunction with the patient.
• Coverage for screening of von Willebrand Disease
  in cases of women with menorrhagia
• Cardiovascular Disease
• Cardiac rehabilitation, diabetes screening and
  self management, nutrition counseling, and
  smoking cessation
• Continued monitoring of adequacy and quality once
  EHB plan is implemented
• Disabilities
• Coverage of assistive technology, home health and
  personal care services, and medical transport
• Culturally sensitive outreach materials that meet
  the needs of those with specific disabilities
• Consideration of medical expenses when
  determining income guidelines for health exchange
• Easily accessible healthcare facilities, offices,
  and equipment for patients with disabilities
  (exam tables, scales and radiological machines,
  etc)

12
Essential Health Benefits

• Children
• Early Periodic Screening Diagnosis and Treatment
  (EPSDT) is the most appropriate benefit package
  for children based on childrens clinical needs
• Inclusion of oral and vision care in the
  Pediatric Services benefit
• Inclusion of pediatric and dental benefits that
  are primarily preventive or screening services
• Inclusion of non-cost considerations in
  establishing EHB investments in children
  through preventive services, screenings, etc that
  reduce health care spending over long term
• Medical necessity requirements found in the
  Medicaid program are most appropriate definition
  for children
• Coverage for in-home personal care,
  mobility-related devices and other durable
  medical equipment
• Age not to be used as basis for limiting services
• Utilize small employer model for pediatric oral
  health services benchmark
• Broad access to all dental plans offering the
  required benefits and meeting qualification
  standards inside the Exchange
• Coverage for medical food and formula for
  children affected by Phenylketonuria (PKU)
• No limits on visits to physical therapy,
  occupational therapy, speech therapy

13
Essential Health Benefits

• Women and Reproductive Health
• Robust coverage of pregnancy and maternity
  benefits such as preconception care, prenatal,
  labor and delivery, postnatal, postpartum care,
  breastfeeding, and mental health for postpartum
  depression.
• Coverage of habilitative services to cover early
  intervention services for premature infants and
  other children with special health care needs
• Coverage for gynecological visits, lab testing,
  as well as indicated treatment for infections
• Coverage of assisted reproductive technologies
  and voluntary sterilization for men and women
• Screenings, counseling, and treatment for all
  STDs for men and women
• Hospice and Palliative Care
• Coverage of hospice and palliative care
• Preventive Care
• Coverage of tests and services needed to prevent,
  detect and treat the early onset of disease
• Exclusion of expensive benefits that only impact
  a few

14
Essential Health Benefits

• Behavioral Health
• Inclusion of strong mental health benefits
  Mental Health Parity and Addiction Equity Act
  covers 8 diagnoses of serious mental illness
  (SMI), with addition of substance use disorders
  (SUDs)
• Robust and routine outpatient benefits for mental
  health and substance abuse services
• Support of inpatient hospital services for acute
  mental illness, medically supervised detox,
  psychotropic and addiction medications,
  behavioral therapy, habilitation and rehab
  services, screening, education and self
  management, intensive case management and ACT
  teams, peer support services, SBIRT Screening,
  Brief Intervention and Referral to Treatment
• Screening for mental disorders in primary health
  care, across the life span and in connection to
  treatment and support systems
• Prescription Drugs
• Assure provider and patient choice of medicines
• Do not impose one drug per class rule for it
  may not meet patients clinical needs, and is
  likely to lead to discriminatory benefit designs

15
Essential Health Benefits

• Chiropractic Services
• Inclusion of chiropractic network and services
  found to increase the health of the general
  population, score high on patient satisfaction
  and proven cost effective.
• Dietician/Nutritional Services
• Coverage of Medical Nutrition Therapy (MNT) by
  Registered Dietitians and Licensed Dietitian/
  Nutritionists
• Exclude pre-authorization or medical review
  requirement (beyond physical referral) for MNT
• Inclusion of unlimited number of visits with a
  Registered Dietician for children and adults
• Alternative minimum of 6 visits with an RD/LDN
  per condition per year, with additional visits as
  needed with physician referral
• Adequate nutrition coverage, allowing for
  proactive treatment of disease conditions such as
  diabetes, hypertension, and obesity
• Coverage for home infusion including enteral
  nutrition support (tube feedings)

16
Essential Health Benefits

• Which plan is the best fit for stakeholders?
• 6 stakeholders specified a plan option in their
  comments, the majority of which support the BCBS
  small group option
• Either BCBS option under Small Group Plans
• BCBS Standard and the BCBS Basic Plans (federal
  plans)
• BCBS small group
• BCBS Small Group or State Employee Plans
• Least expensive BCBS small group plan
• BCBS Small Group HMO Plan FEDVIP for pediatric
• Some concerns mentioned are not possible under
  current guidance (requiring EPSDT, restricting
  cost sharing, broadening provider networks,
  requiring services that are not included in any
  benchmark)
• The small group plans are also the least
  expensive options in terms of premium. Among the
  small group options, premiums are comparable.
• Small group and State Employee benchmarks cover
  all insurance mandates passed before December
  2011.

17
Essential Health Benefits

• Recommendation Based on stakeholder feedback
  received, the BCBS Small Group EPO plan option
  should be Delawares benchmark plan for the
  individual and small group market in 2014 and
  2015.
• This recommendation will be supplemented to
  provide EHB categories such as pediatric
  dental/vision and habilitative services once
  final guidance has been issued by HHS on
  supplement options.

18
QHP Selection Process

• The State has two options to select health plans
  for inclusion in the Exchange
• Select health plans through a procurement-style
  process (otherwise known as selective
  contracting)
• State issues an RFP.
• Health plan issuers respond with their product
  and pricing details.
• State chooses plans from the pool of applicants
  for inclusion in Exchange.
• Select health plans through a certification
  process
• State sets certification standards for qualified
  health plans.
• Health plan issuers submit product and pricing
  information for review.
• State reviews plans to ensure that certification,
  pricing, and accreditation standards are met.
• Plans that meet all criteria are included in the
  Exchange.

19
QHP Selection Process

• CCIIO has stated that, for States participating
  in the full FFE, the federal government will
  pursue a certification process using the federal
  minimum standards.
• There will also be two multi-State plans chosen
  by the federal Office of Personnel Management
  (OPM) offered on every Exchange
• OPM plans will be certified using the same
  process and criteria as the FFE
• Recommendation The State pursue a certification
  process for the Exchange
• Certification standards will likely include
  provisions that go beyond the federal minimum to
  ensure that Delawares insurance market is
  protected from adverse selection while
  contributing to the achievement of the States
  health care goals.
• Final recommendations on certification standards
  will be presented during the October Health Care
  Commission meeting.

20
Public Consulting Group, Inc. 148 State Street,
Tenth Floor, Boston, Massachusetts 02109 (617)
426-2026, www.publicconsultinggroup.com