Nebraska s Health Insurance Exchange Overview of the Essential Health Benefits Public Session August 16, 2012
TODAY'S AGENDA Section 1: Review of Health Insurance Exchanges Section 2: Overview of Essential Health Benefits & the Role of the Exchange Page 2
Page 3 REVIEW OF HEALTH INSURANCE EXCHANGES
WHAT IS AN EXCHANGE? A State-based insurance Exchange is a newly created marketplace that will facilitate the comparison and purchasing of health insurance for individuals and small business employers. The Exchange will certify state-licensed health plans to be able to sell their commercial insurance products through the Exchange. Page 4
OVERVIEW OF ESSENTIAL HEALTH BENEFITS AND THE ROLE OF THE EXCHANGE Page 5
ESSENTIAL HEALTH BENEFITS & THE EXCHANGE» Individuals and small employers may purchase health coverage offered through either the Exchange or an insurer outside the Exchange.» All insurers (whether selling inside or outside the Exchange) will be subject to the same rules regarding essential health benefits.» The Patient Protection & Affordable Care Act (PPACA) includes provisions to lower premiums and cost-sharing obligations for people with lower incomes as long as they purchase insurance through the Exchange Individuals with incomes between 100% and 400% of poverty are eligible for a tax credit to reduce the cost of coverage Page 6
OVERVIEW OF ESSENTIAL HEALTH BENEFITS» The Patient Protection and Affordable Care Act (PPACA) requires health insurance plans sold to individuals and small employers to provide a minimum package of services in 10 categories called Essential Health Benefits.» Essential Health Benefits are the minimum standard to be applied both inside and outside the Exchanges. They include: Ambulatory patient services Emergency services Hospitalizations Maternity and newborn care Mental health and substance use disorder services, including behavioral health Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care Page 7
ESSENTIAL HEALTH BENEFITS, CONTINUED The federal government has informally described the approach it will use to determine essential health benefits via guidance. It has not issued a formal regulation as of yet. Each state must set its own definition of essential benefits for 2014 and 2015 by choosing a benchmark plan. States can choose from among the following options as the benchmark: The largest plan by enrollment of the three largest small group plans in the state One of the three largest state employee health plans by enrollment One of the largest federal employee health plan options by enrollment, or The largest HMO plan offered in the state s commercial market by enrollment Page 8
ESSENTIAL HEALTH BENEFITS, CONTINUED» The plan that Nebraska selects as the benchmark plan will become the essential health benefits for Nebraska and all health plans offered in the individual and small group market must offer equivalent benefits» Insurers are not required to replicate the benefits in the benchmark plan, but the benefits offered must be actuarially equivalent to those in the benchmark plan This means that the benefits are of approximately the same value in each of the 10 required categories Page 9
ESSENTIAL HEALTH BENEFITS, CONTINUED» If a state requires benefits that exceed those included in the essential health benefits package, the state has to pay the cost of these additional mandates How this money is paid or where it goes has not been provided by the federal government at this time Page 10
ESSENTIAL HEALTH BENEFITS-WHAT S NEXT? Decision must be made by September 30, 2012 or the federal government will choose the largest small group health plan. Using federal grant funds, NDOI contracted with Mercer to conduct a study regarding the Essential Health Benefits: Evaluate the largest plan by enrollment of the three small group plans, the largest HMO, the largest state employee plan and the federal employees health insurance plan Identify missing benefits Evaluate the coverage of mandated benefits in the selected plans Page 11
NEBRASKA S ESSENTIAL HEALTH BENEFITS STUDY» Based on Mercer s study, the state has four choices 1. Coventry HMO 2. BCBS BluePride(Small group) 3. BCBS BlueChoice(State Employee Plan) 4. BCBS Federal Employee Health Benefits Programs (FEHBP)» Based on the study, it is Mercer s belief that: The core benefits covered by the selected plans are comprehensive and cover virtually all of the required essential health benefit services There is a potential for premiums to increase by 0.0% to 0.3% for the costs of habilitative services related to the treatment of autism spectrum disorders (if defined as a covered benefit) The State would be responsible for the costs of mandated TMJ coverage, this could increase premium between 0.0% to 0.3%. Page 12
QUESTIONS / DISCUSSION Page 13