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Essential Health Benefits and QHP Selection Process Recommendations


Essential Health Benefits and QHP Selection Process Recommendations Health Care Commission September 6, 2012 * * PCG Health ... – PowerPoint PPT presentation

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Title: Essential Health Benefits and QHP Selection Process Recommendations

Essential Health Benefits and QHP Selection
Process Recommendations
  • Health Care Commission
  • September 6, 2012
  • Governance Model Revision
  • Update Exchange Timeline through January 2014
  • Essential Health Benefits Benchmark
  • QHP Selection Process Recommendation

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

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
  • 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

Update Exchange Timeline
  • December 2012
  • Exchange readiness review conducted by Federal
  • 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
  • January 2014
  • Plan coverage year commences

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
  • 8. Laboratory services
  • 9. Preventive and wellness services and chronic
    disease management
  • 10. Pediatric services, including oral and vision

Essential Health Benefits
  • The State has the option to choose an Essential
    Health Benefits benchmark from among several
  • 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
  • HMO
  • Consumer Directed Health (CDH) Gold
  • The three largest federal employee health benefit
  • Blue Cross/Blue Shield FEHP Standard Option
  • Blue Cross/Blue Shield FEHP Basic Option
  • Government Employees Health Association (GEHA)
  • The BCBS Small Group EPO plan currently has the
    largest enrollment of the small group options

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

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
  • 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
  • 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
  • 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

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

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,

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

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
  • 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

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
  • 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

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/
  • 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)

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
  • 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
  • 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

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
  • 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.

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
  • 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
  • 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

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.

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