1 Diabetes Coverage in the Health Insurance Exchanges & Essential Health Benefits Dr. LaShawn A. McIver, MD, MPH National Director, Public Policy & Strategic Alliances American Diabetes Association
2 O Presentation Outline: American Diabetes Association Overview Diabetes 101 Diabetes Coverage in Health Insurance Exchanges & Essential Health Benefits
4 People with diabetes cannot end up with less coverage than they currently have as a result of health care reform.
5 American Diabetes Association Overview
6 What We Do -Research Over the years, the Association has invested more than $530 million in diabetes research In 2010, the Association made $34.1 million available to support diabetes research This funding supported 338 awards at more than 125 leading research institutions
7 What We Do -Education DIABETES receives 25,000 calls a month Health fairs, programs, camps and other events target hundreds of thousands of people around the country Publish award-winning books and Diabetes Forecast magazine for consumers Provide journals, books, and clinical guidelines to health care professionals around the world
8 What We Do -Advocacy Seek increased federal and state funding for diabetes prevention, treatment and research Promote public policies to prevent diabetes Advocate to improve the availability of accessible, adequate and affordable health care Fight discrimination people with diabetes face at school, work, and elsewhere in their lives.
9 Diabetes 101
10 What Happens When We Eat? After eating, most food is turned into blood glucose, the body s main source of energy.
11 Normal Blood Glucose Control In people without diabetes, glucose stays in a healthy range because Insulin is released at the right times and in the right amounts Insulin helps glucose enter cells
12 High Blood Glucose (Hyperglycemia) Too little insulin is made In diabetes, blood glucose builds up for several possible reasons Liver releases too much glucose Cells can t use insulin well
13 Two Main Types of Diabetes Type 1 diabetes Pancreas makes too little or no insulin Type 2 diabetes Cells do not use insulin well (insulin resistance) Ability for pancreas to make insulin decreases over time
14 Type 1 Diabetes 1 in 10 people with diabetes have type 1 Most people are under age 20 when diagnosed Body can no longer make insulin Insulin is always needed for treatment
15 Before and After Insulin Treatment
16 Type 2 Diabetes 9 in 10 people with diabetes have type 2 Most people are over age 40 when diagnosed, but type 2 is becoming more common in children and teens Type 2 is more likely in people who: Are overweight Belong to certain ethnic groups Have a family history of type 2
17 What is Prediabetes? 1 in 3 American adults have prediabetes Occurs before type 2 diabetes Blood glucose levels are higher than normal but not yet diabetes Most people with prediabetes don t know they have it
18 Blindness Kidney disease Nerve damage Amputation Heart attack Stroke Hyperglycemia Can Cause Serious Long-Term Problems Chronic complications of diabetes Loss of circulation in arms and legs
19 26 million American have diabetes, but 79 million Americans have prediabetes, many of which are unaware of their risk to develop diabetes.
20 Burden of Diabetes in the United States Total direct and indirect cost of diagnosed diabetes is $174 billion a year Total diabetes-related costs exceed $218 billion when you add gestational diabetes, prediabetes and undiagnosed diabetes 1 in 5 health care dollars is spent caring for someone with diagnosed diabetes 1 in 10 health care dollars is attributed to diabetes
21 Diabetes Coverage in Health Insurance Exchanges & Essential Health Benefits
22 Why Did People with Diabetes Need Health Care Reform? Barriers for People With Diabetes: Denial based on pre-existing conditions Very high premiums based on diabetes Annual and lifetime caps on benefits Insurance plans which didn t cover the most basic diabetes needs, leaving people with large expenses in addition to the cost of insurance
23 After ACA is Fully Implemented A diagnosis of diabetes is no longer a lawful reason to charge a person more or deny health insurance coverage, ending the current system that sanctions such discrimination.
24 What Else Does the Affordable Care Act Do For People with Diabetes? Requires most plans to provide certain preventive services without cost-sharing Closes the Medicare Donut-hole Removes annual and lifetime limits on insurance coverage and prohibits denial of coverage for preexisting conditions Requires chain restaurants to post nutritional content of food served
25 National Diabetes Prevention Program The ACA authorized The National Diabetes Prevention Program: A nationwide expansion of a proven approach to diabetes prevention through community-based diabetes prevention sites, national training programs, public awareness and provider education campaigns, and informed referral networks The ACA also created the Prevention and Public Health Fund, dedicated funding for public health programs designed to prevent disease and promote wellness. So far, the National Diabetes Prevention Program has received $10 million from the Fund
26 How the Affordable Care Act Helps Parents of Children with Diabetes Stops insurance companies from denying coverage for children with pre-existing conditions, like diabetes Allows parents to keep their children up to age 26 on their insurance plan Requires health insurers to provide consistent, easy to understand information about what the plan covers, so parents can select the plan that is best for their family
27 Health Insurance Exchanges Most people get coverage through large employer plans works relatively well for most people Individuals especially low wage and small businesses face hurdles to getting coverage Exchanges, together with insurance reforms, will provide better way for individuals and small businesses to get coverage
28 What Will Exchanges Do for Individuals? One stop shopping - gateway to coverage for 30 million people Allow consumers to make apples to apples comparisons easier shopping, clearer choices among four levels of benefits Federal subsidies for premiums and out-of-pocket costs for people below 400% poverty $45,000 for an individual (premium max $4,275) $92,000 for a family of four (premium max $8,740)
29 Federal Rules Health Insurance Exchange After public comment opportunity, final rule took effect 5/29/2012 Overall, gives states considerable flexibility around key design choices Set minimum standards that all exchanges must meet Outlined areas where states can use their discretion or rely on existing state insurance rules and practices
30 State Choices The whether options Whether to operate state exchange, enter partnership with federal government or punt to federal government Whether to operate separate exchanges for individuals and businesses (SHOP exchange) or combine them Whether to operate state-wide exchange, multiple exchanges within state, or regional exchange with other states
31 State Choices, cont d The how options How to set up the governance of exchange Public agency, non-profit, or quasi-gov t entity How to define eligible business Default is employers with up to 100 employees States can define as up to 50 employees In 2017, can allow businesses with more than 100 employees Whether to operate a Basic Health Plan for those up to 200% of poverty ($22,300 for individual, $46,000 for family of 4)
32 Rules Still to Come Federally facilitated exchange: what will a federal exchange look like, and what can states expect if they partner with the federal government Federal officials previewed options for states to partner States do plan management States do select consumer assistance functions States do both In all cases, federal gov t does eligibility and enrollment (and share info with state agencies)
34 Coverage for diabetes in Health insurance exchanges Ensure the adequacy of benefits offered by health plans Prevent adverse selection Coordinate Medicaid and the Exchange so as to foster continuity of care and coverage for those who may shift between these coverage options due to fluctuations in their income
35 Prevent conflicts of interest in the Exchange governance structure and include the consumer perspective, including those with chronic disease to ensure the governance structure is responsive to the needs of patients with chronic disease Ensure accessibility and transparency of plan and cost information, as well as information on consumer protections and enrollment assistance Provide for a robust public outreach and education initiative, which should begin as early as possible
36 Overview of Essential Health Benefits in Health Reform Essential Health Benefits ACA to expand coverage to those without and to improve coverage for those who have it EHB part of both those goals: Set standard for coverage that is adequate Allow consumers to compare plans and understand benefits Protect against insurers using benefit design to avoid higher cost patients
37 Requirements for Health Coverage Law lists 10 broad categories: Ambulatory patient services (i.e., doctor visits); Emergency services; Hospitalization; Maternity and newborn care; Mental health and substance abuse disorder services, including behavioral health treatment; Prescription drugs; Rehabilitative and habilitative services and devices; Laboratory services; Preventive and wellness and chronic disease management services; Pediatric services, including oral and vision care.
38 Other Requirements Under the Law EHB should be similar to typical employer plan All new plans in individual and small group market must offer EHB (not large group plans, self insured or grandfathered plans) The law s limits on out-of-pocket costs and prohibition against annual and lifetime limits apply only to the EHB EHB only includes the services and benefits to be covered. It does not address what patients will pay out of pocket for those benefits and services
39 Other Requirements Under the Law When defining EHB, federal and state officials must consider: Whether there is an appropriate balance among categories (i.e., sicker patients should not get less) Whether the benefit design would discriminate against individuals because of their age, disability, or expected length of life The health care needs of diverse segments of the population When essential benefits are defined, if services provided can be denied based on age, expected length of life, disability, degree of medical dependency or quality of life
40 What did HHS Propose? Each state will choose one EHB from among 10 plans that are currently in the state: Largest plan by enrollment in any of the top 3 small group market products Any of the largest 3 state employee plans Any of the largest 3 federal employee plans Largest insured commercial non-medicaid HMO These existing plans known as benchmark plans - include not just services/treatments covered but any limits that may apply (i.e., visit limits)
41 HHS Proposal, cont d If a benchmark doesn t cover all 10 categories required under the ACA, benefits must be added If a benchmark doesn t include coverage required by state law (state mandates), a state can add it to their EHB at state cost for those in qualified health plans (whether subsidized or not) If state does not choose an EHB, the default plan will be largest plan by enrollment in largest product in small group market
42 Diabetes Coverage in EHB Diabetes screening for individuals at high risk Services as determined by a treating health care provider Prescriptions Durable medical equipment (including blood glucose testing equipment and supplies and insulin pumps and associated supplies) A yearly dilated eye exam by an eye-care professional with appropriate follow-up care as medically needed; podiatric services Diabetes education (including diabetes outpatient selfmanagement training services); and medical nutrition therapy services Services related to pregnancy (including screening for diabetes, monitoring and treatment for women with preexisting diabetes and gestational diabetes, postnatal screening)
43 Why is this important for people with diabetes?
44 What Can State Advocates Do? Requests to state: State must use transparent process to choose EHB Make clear the factors state will use in making a choice Allow for public input Make publicly available plan documents for each benchmark option to know in detail what is covered and what is not Ensure enforcement of patient protections and other ACA requirements
45 What s Next? [If the Supreme Court upholds ACA] In September 2012, insurance plans are required to provide consumers with standardized, easy to understand information about what the plan covers, including an example for treating type 2 diabetes All new plans beginning on or after August 1, 2012, will have to provide pregnant women with coverage for diabetes screening at the first prenatal visit and screening for gestational diabetes between weeks gestation without cost to the patient
46 In 2014: What s Next? [If the Supreme Court upholds ACA] Insurance companies cannot deny coverage for adults with pre-existing conditions like diabetes Insurance companies cannot charge higher premiums based on gender or health status People who do not get insurance through their employers, or who work for small companies, can buy quality, affordable insurance through a consumer-friendly health insurance marketplace ( Exchanges )
47 What s Next? [If the Supreme Court upholds ACA] Most plans must offer a minimum set of health benefits including coverage of preventive and wellness services and chronic disease management Those up to 400% of the poverty level are eligible for premium tax credits and cost sharing subsidies Medicaid is expanded to cover those up to 133% of the poverty level
48 What s Next? [If the Supreme Court strikes down ACA] States, insurance companies and Congress can take various actions to replace provisions contained in the ACA The impact of the Supreme Court decision will vary from state-tostate, and among different insurance plans
49 What s Next? [If the Supreme Court strikes down ACA] People with diabetes must fight back so that we are not once again denied health insurance.
50 The End Contact Information: LaShawn A. McIver, MD, MPH Managing Director, Public Policy and Strategic Alliances Information for the Public: DIABETES Special thanks to JoAnn Volk from Georgetown Health Policy Institute for contributing to this presentation