The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010, together commonly referred to as the
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1 The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010, together commonly referred to as the Affordable Care Act (ACA), requires that health insurance products sold to individuals and small groups cover Essential Health Benefits (EHB) encompassing ten broad and comprehensive areas of health insurance coverage. The ACA defines EHB as the scope of benefits provided under a typical employer plan, as determined by the Secretary. CCIIO guidance issued February 27, 2015, set forth that states would be allowed to choose a new EHB benchmark plan for the 2017 plan year. The new EHB benchmark plan will be chosen by each state from one of four benchmarks, which comprise ten candidate plans in total. These candidate plans for any state include the three largest Federal Employee Health Benefits Program (FEHBP) plans, the three largest state employee benefit plans, the three largest small group commercial insurance plans, and the largest commercial health maintenance organization (HMO) plan.
2 These plans comprise the following: Category Plan Three Largest Federal Employee Health Benefit Program Options Three Largest State Employee Health Plans Three Largest Small Group Employer Plans Anthem BCBS FFS Standard Anthem BCBS FFS Basic Government Employee Health Association (GEHA) Plan FFS Standard State Employee Health Plan (SEHP) A State Employee Health Plan (SEHP) B State Employee Health Plan (SEHP) C BCBS Shield of Kansas Comprehensive Major Medical Blue Choice PPO BCBS of Kansas Comprehensive AffordaBlue Blue Choice PPO Largest insured commercial non-medicaid HMO UnitedHealthcare Choice Plus PPO BCBS of Kansas City Blue-Care HMO The ten EHB categories are as follows: 1. Ambulatory patient services; 2. Emergency services; 3. Hospitalization;
3 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; and 10. Pediatric services, including oral and vision care. No matter which of the candidate plans is chosen as the state s benchmark plan, all ten of the benefit categories must be included in the final Essential Health Benefits package. If the chosen benchmark plan does not adequately provide the services in each of the above benefit categories, the benefits of the chosen benchmark plan must be supplemented to create the final EHB package for the State. The following table lists the benefit categories for each plan, using a to indicate coverage and an X to indicate uncovered or insufficient benefits.
4 Essential Health Benefit category 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, wellness, and disease management 10. Pediatric services, including oral and vision care Federal State Small Group HMO Stan Basic GEHA BCBS BCBS BCBS BCBS BCBS United BCKC Blue Care HMO dard Plan Plan Plan C Major Afforda Healthcare A B Medical Blue X X X X X X X X X X X X X X X X X X X
5 Habilitative Services In EHB category #7, habilitative services are not explicitly included in the benefit designs of some of the candidate EHB plans. HHS defines habilitative services as: Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Children s Vision and Oral Benefits Vision and oral benefits for children are a required essential health benefit under the ACA. All ten candidate benchmark plans have lean pediatric vision and oral benefits that are insufficient to meet the minimum standard of an EHB. Kansas currently mandates pediatric dental anesthesia (which is reflected in SEHP and small group plans); however, this is insufficient to meet the full criteria of providing children s vision and oral benefits. The Department intends to supplement Children s Oral and Vision benefits with the KS Medicaid/CHIP benefits. Mental Health and Substance Use Benefits and Parity The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires that plans provide behavioral health benefits offer these benefits on a level that is at parity with traditional medical and surgical benefits offered under the same plan. Under MHPAEA, deductibles, copayments, coinsurance, and treatment limitations (such as visit or day limits) applicable to mental health and substance use disorders may be no more restrictive than the cost sharing and treatment limitations applied to substantially all medical and surgical benefits. State and Federally Mandated Benefits All plans currently sold in the state must be compliant with current Kansas mandates. In addition, small group and individual plans sold in Kansas are subject to federal mandates requiring coverage of specified preventive health services as follows. o U.S. Preventive Services Task Force (USPSTF) A and B recommended benefits o Women s preventive healthcare services recommended by the Health Resources and Services Administration o HRSA Bright Futures designated pediatric services
6 Services in the above categories must be provided to the member with no cost sharing. Many of these listed preventive services are highly specific, and may not be explicitly described in the plan documents. Some preventive and wellness services are not outlined in the certificate of coverage, but are described in member handbooks and brochures. At times, preventive screenings will lead to further diagnostic exams which are not considered preventive in nature and will be charged as usual. Benefit Category Details In selecting the benchmark plan, the State and other stakeholders may also wish to consider what specific services or benefits are explicitly excluded. The Table below covers specific services of interest where C is covered, NC is not covered and * is neither explicitly included nor excluded. Coverage may include limitations: E.g. coverage for bariatric surgery under the Kansas State Employee Health Plan requires patients to complete a 90 day multi-disciplinary regimen of surgical preparation including supervised dieting and exercise programs.
7 Benefits provided with non-uniform coverage by the candidate plans Federal Plans State Plans Small Group Plans HMO Stan Basic GEHA BCBS BCBS BCBS dard Plan A Plan B Plan C BCBS Major Medical BCBS Afforda Blue United Health Care Ambulatory patient services Acupuncture C C C NC NC NC NC NC C NC Chiropractic (therapeutic, adjustive, manipulative) C C C C C C C C C C Genetic evaluation and counseling C C NC C C C C C C * Genetic testing C C NC C C C C C C * Home health care C C C C C C C C C C Hospice C C C C C C C C C C Infertility treatment services C C C C C C C C C C Respite care C C * NC NC NC NC NC C C TMJ services NC NC NC NC NC NC C C C C Hospitalization Bariatric surgery C C C C C C NC NC C C Orthognathic * * C C C C C C C C Surgery Skilled nursing NC NC C C C C NC NC C C facility Mental health and substance use disorder services, including behavioral health treatment BCKC Blue Care HMO
8 Inpatient NC NC C C C C NC NC C C Residential Drug Treatment Facility Prescription drugs Erectile NC NC NC NC NC NC C C C C dysfunction drugs Infertility drugs C C NC NC NC NC C C C C Tobacco C C C * * * C C C C cessation Rehabilitative and habilitative services and devices Applied * * * C C C * * * * Behavioral Analysis for Autism Spectrum Disorders Cardiac C C C C C C C C C C rehabilitation Durable medical C C C C C C C C C C equipment Eyeglasses C C C C C C C C C C
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.myhpnonline.com or by calling (702) 242-7300 or 1-800-777-1840.
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This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling 1 866 375 0775. Important Questions Answers Why this
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