ACP Analysis of the Essential Health Benefits Bulletin, Issued by the HHS Center for Consumer Information and Insurance Oversight (CCIIO)

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1 ACP Analysis of the Essential Health Benefits Bulletin, Issued by the HHS Center for Consumer Information and Insurance Oversight (CCIIO) Introduction and background: Summarizes the essential benefit package provision of the ACA and outlines public and other input. Not applicable. ACP Policy Discusses Department of Labor employer plan survey Outlines IOM essential benefit package recommendations and notes public comments on the report. Consumers generally support a more comprehensive benefit package with specific benefits indicated while employers and insurers preferred a general package with more flexibility. Consumers were concerned that small group market plans may not reflect the typical employer plan referenced in the ACA and requested that state benefit mandates be included in the package. B. Summary of Research on Employer Sponsored Plan Benefits and State Benefit Mandates. Not applicable. Summarizes analysis of employer benefit offerings and notes that small group, state employee, Federal Employees Health Benefits Program (FEHBP) Blue Cross Blue Shield (BCBS) Standard Option and Government Employees Health Association plans do not differ significantly in the range of services they cover although they differ in cost-sharing levels. Plans generally cover health care services in all of the 10 statutory benefit categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services (incl. behavioral health treatment), prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and

2 chronic disease management, and pediatric services (incl. oral and vision care). Among the differences between plans, FEHBP BCBS Standard covers bariatric surgery, smoking cessation programs and preventive and basic dental care and other benefits that may not be consistently covered by small employer plans. Depending on state small group benefit mandates, some small group plans may cover in-vitro fertilization, autism spectrum disorder treatment, etc, not typically covered by FEHBP. FEHBP BCBS standard covers 95% of state and provider mandate categories. There is variation among states as to whether state benefit mandates apply to State employee benefit plans C. Intended Regulatory Approach Generally reflects ACP policy. HHS approach seeks to: Encompass 10 categories of services identified in the statute; Reflect typical employer health benefit plans Reflect balance among the categories Account for diverse health needs across many populations Ensure there are no incentives for coverage decisions, cost sharing or reimbursement rates to discriminate impermissibly against individuals because Flexibility should be provided for states to investigate different approaches to expanding coverage, controlling costs, identifying funding sources, and reducing barriers to access and quality, provided that such state based approaches contribute to the overall goal of providing all Americans with access to affordable coverage, subject to national standards to assure portability and access to the basic benefits package. State initiatives, while encouraged, are not a substitute for federal action when state initiatives are lacking or ineffective. (Core

3 of their age, disability, or expected length of life; Ensure compliance with Mental Health Parity and Addiction Equity Act of 2008; Provide States a role in defining EHB; And balance comprehensiveness and affordability for those purchasing coverage. Proposes that EHB be defined by a benchmark plan selected by each State. Benchmark plan would serve as a reference plan reflecting scope of services and limits offered by a typical employer plan as required by ACA. Approach is similar to that of Children s Health Insurance Plan benefit package. According to HHS this allows a balanced approach that addresses consumers need for comprehensiveness and affordability. Principles on Health Insurance Coverage) ACP supports parity of benefits for physician services for mental and medical illness in all insurance plans (HoD 97; reaffirmed BoR 08) The public, patients, physicians, insurers, payers, and other stakeholders should have opportunities to provide input to health resource allocation decision making at the policy level. (How Can Out Nation Conserve and Distribute Health Care Resources Effectively and Efficiently?) Small employers should have new options for obtaining coverage, including access to the variety and types of health plans offered to federal employees. (Recommendation 5: Achieving Affordable Health Insurance Coverage for All Within Seven Years, 2008) Provide everyone access to affordable coverage, whether provided through a single payer or pluralistic financing model, that includes coverage for a core package of benefits, including preventive services, primary care services, including but not limited to chronic illness management, and protection from catastrophic health care expenses. (Achieving a High Performance Health Care System with Universal Access) Sufficient resources should be devoted to developing needed data on clinical and cost effectiveness of medical interventions for comparative, evidence based evaluations that should serve as the basis for allocation decisions about the utilization of health care resources. There should be a transparent and politically acceptable process for making health resource allocation decisions with a focus on medical efficacy, clinical effectiveness, and need, with consideration of cost based on the best available medical evidence.

4 Multiple criteria should be considered in determining priorities for health care resources. Factors that might be considered high priority, in addition to clinical effectiveness and costs, should include patient need, preferences, and values; potential benefit; safety; societal priorities that include fiscal responsibility and equitable access; quality of life gained, consistent and compliant with the Americans With Disabilities Act; public health benefit; impact on families and caregivers; a balance between cost and clinical effectiveness to minimize adverse economic consequences on current and future generations. (How Can Out Nation Conserve and Distribute Health Care Resources Effectively and Efficiently?) ACP promotes the inclusion of clinically effective preventive services among the benefits to be provided by all private and public health insurance programs. ACP seeks appropriate reimbursement for physicians providing clinical preventive services according to the CPT-4 preventive medicine codes by all private and public health insurers. (Insurance Coverage of Clinical Preventive Services) Employers and health plans should consider adopting value based benefit design programs that use comparative research on clinical outcomes and cost effectiveness developed by an independent entity that does not have an economic interest in the benefit determinations.(controlling Health Care Costs: Comparative Effectiveness Research) Four Benchmark Plan Types Generally reflects ACP policy.

5 For 2014 and 2015: The largest plan by enrollment in any of the three largest small group insurance products in the State s small group market. Any of the largest three State employee health benefit plans by enrollment; Any of the largest three national FEHBP plan options by enrollment; or The largest insured commercial non- Medicaid Health Management Organization operating in the State. Tax credit recipients should have the option of buying coverage through state purchasing group arrangements modeled after the Federal Employees Health Benefits Program, giving them the same types and variety of health plan options now available only to federal employees, or from qualified non-group insurers. Plans that participate in the purchasing group would be required to agree to uniform new federal rules on risk-rating and renewability as a condition of participating in the program. (Recommendation 4: Achieving Affordable Insurance for All Within Seven Years ) Benchmarks for 2016 and subsequent years will be determined based on evaluation and feedback. Benchmarks would be used for individual and small group plans and Exchange-based plans (presumably this means that the benchmark plan will be required for plans operating inside and outside of the Exchange). (from the supporting text) To participate in such a pool, a health plan should be licensed in the applicable state (or be a FEHBP-participating national indemnity plan exempt from state regulation under FEHBP); should provide requested information, described below, to pool operators; and should offer coverage in one of the following three categories: If a State does not choose a benchmark, The default plan would be the largest small employer plan operating in the State. In , if a State chooses to include state benefit mandates in their benchmark plan, e.g. a small group market plan, the state mandated benefits would be included in the State EHB package. In the event that the State chooses to mandate services not covered under the benchmark plan, they will have to fund such services. HHS will evaluate the benchmark approach for the calendar year 2016 and will develop an approach that may exclude some State benefit mandates from inclusion in the State EHB package. a) The most highly subscribed FEHBP plan among federal employees during the prior year 1) Benchmark coverage. Such coverage should have benefits not less than, and out-of-pocket cost- sharing not greater than, one of the following: b) Non-waivered Medicaid or SCHIP coverage in the state or c) The most highly subscribed plan in the state among either state employees or commercial, non- Medicaid HMO enrollees during the prior year. 2) Benchmark-equivalent coverage. To qualify as

6 benchmark-equivalent, a plan should: In instances where the benchmark plan does not cover a mandated benefit category, States may have to supplement the benchmark plan to ensure coverage. For instance, if the benchmark plan does not cover prescription drugs, the State may supplement the benchmark with the prescription drug coverage benefit from the FEHBP plan. Categories that are typically not covered are habilitative services, pediatric oral services, and pediatric vision services. The Bulletin notes that HHS seeks comments on the definition of habilitative and pediatric oral and dental care. a) Have an aggregate actuarial value not less than a benchmark plan and b) Cover the most recent set of essential benefits recommended by an expert Commission and adopted by Congress. 3) Alternative coverage should offer benefits not less than, and out-of-pocket cost-sharing not greater than, an FEHBP fee-for-service or HMO plan that does not provide benchmark coverage. Staff comment: Similar benchmark approach to ACP s Seven Year Plan recommendation, although the State would be allowed to choose from among the top 3 enrolled plans rather than the most highly subscribed plan as recommended by ACP. Note that in 2016, HHS will reevaluate the benchmark approach and may exempt some State mandates from the Exchange benchmark. It is unclear what criteria will be used to determine which services may be excluded. According to the Bulletin, this approach is based on the Children s Health Insurance Program benchmark structure. If a State chooses a benchmark plan that does not include some of the existing State benefit mandates, the State would have to cover the cost of those mandates outside of the EHB package. For instance, FEHBP BCBS Standard does not cover in-vitro fertilization and certain autism therapy services. If a State mandates coverage of these benefits and chooses the FEHBP as its benchmark, it may have to cover the costs of these services. Additionally, some states mandate very few benefits in the small group market. Idaho, for instance, requires coverage of only 13 benefits. If a State with limited benefit mandates chooses the

7 typical small business plan as its benchmark, it may be less comprehensive than a plan in Rhode Island, where nearly 70 services are mandated. The statutory requirement that EHB cover all 10 benefit categories and reflect the scope of benefits provided by a typical employer plan may help ensure an appropriate balance of comprehensiveness and cost. Mental Health and substance Use Disorder Services and Parity Reflects ACP policy Outlines the mental health parity law and notes that the ACA expands the parity requirement to small group and individual health plans. Notes that coverage of mental health and substance use disorder is one of the EHB categories and must be covered in individual and small group markets. ACP opposes limitations on benefits and higher copayment/deductible payment for physician services for evaluation and management services (the CPT codes series) that are submitted with 1997 ICD-9 codes ACP will seek legislative and/or regulatory means to require that Medicare restore its payment to physicians for evaluation and management services submitted with diagnosis codes 1997 ICD-9 codes to the same level for evaluation and management codes for medical diagnoses. ACP supports the ultimate parity of reimbursement for physician services for medical and psychiatric diagnoses (1997 ICD-9 codes ) by all payers. (HoD 97; reaffirmed BoR 08) (Parity of Benefits for Physician Services for Mental and Medical Illness in All Insurance Plans) Benefit Design Flexibility HHS intends to require that a health plan offer benefits that are substantially equal to the benefits of the benchmark plan selected by the State and modified as necessary to reflect the 10 coverage categories. Similar to CHIP, we intend to propose that a health insurance issuer have some flexibility to adjust benefits, including both the ACP supports giving States some flexibility in determining coverage levels, but this provision may grant that power to health insurance issuers. Flexibility should be provided for states to investigate different approaches to expanding coverage, controlling costs, identifying funding sources, and reducing barriers to access and quality, provided that such state based approaches contribute to the overall goal of providing all Americans with access to affordable coverage, subject to national standards to assure

8 specific services covered and any quantitative limits provided they continue to offer coverage for all 10 statutory EHB categories. Any flexibility provided would be subject to a baseline set of relevant benefits, reflected in the benchmark plan as modified. portability and access to the basic benefits package. State initiatives, while encouraged, are not a substitute for federal action when state initiatives are lacking or ineffective. (Core Principles on Health Insurance Coverage) We are considering permitting substitutions that may occur only within each of the 10 categories specified by the ACA. However we are also considering whether to allow substitution across the benefit categories. If such flexibility is permitted we seek input on whether substitution across categories should be subject to a higher level of scrutiny in order to mitigate the potential for eliminating important services or benefits in particular categories. In addition, we intend to require that the substitution be actuarially equivalent, using the same measures defined in CHIP. Staff comment: Provision may give insurers significant flexibility over EHB coverage. ACP may want to recommend that strong oversight be established to ensure that less appropriate or effective services are not substituted for evidence- effectiveness information be consulted whenever possible to encourage high-value based, high-value primary care services. The College may also recommend that comparative care. Similar to Medicare Part D, plans must cover categories and classes set forth in the benchmark, but may choose the specific drugs that are covered within categories and classes. Updating Essential Health Benefits We will assess whether enrollees have difficulties with access for reasons of coverage or cost, changes in medical evidence or scientific advancement, market changes not reflected in the benchmarks and the affordability of coverage as it relates to EHB. An expert advisory commission should be created to recommend a core set of benefits that participating health plans will be encouraged to offer. (Recommendation 7: Achieving Affordable Health Insurance Coverage for All Within Seven Years, 2008) We invite comment on approaches to gathering information and making this assessment. Under the benchmark framework, we note that the provision of a substantially equal standard would allow

9 health insurance issuers to update their benefits on an ongoing basis to reflect improvements in the quality and practice of medicine. We also intend to propose a process to evaluate the benchmark approach.

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