Essential Health Benefits
States will need to analyze how their benefit mandates compare with federal minimum requirements established by the ACA and decide whether to continue, add to or eliminate any state-mandated benefits.
*Milestone details:
*Full name: Compare current state benefit mandates with federal laws, regulations, and the essential health benefit packages and identify any needed updates.
*Relevance to the ACA:
The ACA establishes federal benefit mandates that all states must follow. The ACA also permits states to establish their own benefit mandates.
§1302 – Establishes the essential benefit package levels that define qualified health plans.
§1311 – Allows states to add additional benefit requirements to qualified health plans; costs would be borne by states rather than the federal government.
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Illinois
Thanks Kris fior your helpful answers to this issue
Connecticut
Looking for a directory of some type that will have the Evidence of Coverages for each State EHB benchmark plan. Has anyone found one?
District of Columbia
Hi Amy: We are keeping track of Evidence of Coverage documents for states as we find them on our "Digging in to Benchmark Plan Details" chart: http://www.statereforum.org/analyses/state-progress-on-essential-health-.... Hope this helps!
Illinois
Thank you Colin. That is very helpful information.
California
I'm interested in what other states are doing with respect to stand-alone plans and the pediatric dental EHB. It appears the federal regulations are essentially making pediatric dental an optional benefit if stand alone plans are participating in exchanges. That seems counter to the purpose of EHBs. At the same time, it seems odd to require childless adults to purchase stand alone pediatric dental coverage they don't need. Has any state identified an approach that allows stand alone plans to participate but that preserves pediatric dental as an EHB? In CA we are trying to have the same policies apply inside and outside the exchange. The federal regulations add an additional challenge for us since they have different rules on this for the outside market.
District of Columbia
Teri, that's a tough one. The statute includes language saying that stand-alone dental plans must be allowed to participate "either separately or in conjunction with" QHPs to offer the pediatric dental EHB inside the exchanges. While it would be possible to interpret this to mean that a state exchange can decide whether they participate separately or in conjunction with QHPs, HHS has interpreted this this to mean that it is the plans' prerogative. So while it is unlikely that a state could force stand-alones to contract with QHPs or force QHPs to embed the dental benefit, it is conceivable though, that a state exchange could decide to require the purchase of this benefit only for families that have qualifying children. However, given the fact that QHPs in the small group and individual markets outside of the exchanges must either embed the dental benefit or be "reasonably assured" that enrollees have pediatric dental coverage that is exchange-certified to fulfill the EHB requirements, it would be worth exploring whether those same QHPs plan to offer an embedded dental benefit inside the exchange.
Illinois
Do any of the Partnership Exchange States have a simple, consumer-friendly chart or presentation on the impact of stand-alone dental plans inside and outside the Exchanges? Thanks
District of Columbia
I haven't seen a chart on this but I can tell you that most of the market reforms and many other consumer protections, including: bans on rescission and denial for pre-existing conditions, right to external appeals process, fair premiums, and cost-sharing reductions, do not apply to stand-alone dental plans.
However, stand-alone dental plans may not have annual or lifetime dollar limits on coverage and must abide by many QHP certification standards including licensure, inclusion of essential community providers, network adequacy, and actuarial value standards (though there are separate AV targets for stand-alone dental benefits).
Additionally, pediatric dental benefits provided through a stand-alone dental, unlike those embedded in a QHP, can have separate and additional out-of-pocket maximums beyond those established by the ACA and because of the way the IRS is interpreting the premium tax credit rule, families who purchase their pediatric dental benefits through a stand-alone plan my not receive a tax credit sufficient to cover the cost of those dental benefits.
Texas
Colin gave a good review of the market reforms, so I wanted to touch on Teri's question.
Numerous state marketplaces are reviewing policy issues regarding the required purchase of dental. Federal guidelines are providing flexibility to states on how they incorporate dental. The ACA is very clear that separate dental policies shall be allowed to be offered on Exchanges, and when they are a QHP shall not fail to be certified on the basis of not including pediatric dental meeting the EHB package. NADP is tracking and responding to state inquiries related to dental coverage within the ACA
From our perspective it seems many states want to continue to parallel the current marketplace as dental benefits are very diverse and compete well on cost, plan design and provider networks. If a state has concern on adverse selection related to pediatric dental (and whether their state will require medical carriers to embed dental on the private market) states are considering mandating the purchase of dental for children, which would be enforced through the IT and enrollment process, not by requiring all QHPs to embed dental. In addition, states that are making the choice for voluntary purchase of pediatric dental have stated they want to a parallel the FFM or allow consumers to keep coverage they currently have on the private market.
The attached draft chart is our current tracking on two of the issues you touched on, it includes decisions made by: FFM, AR, CA, CO, HA, IA, KY, MD, MN, NV, NY, OR, RI, WA, WI and VT. If other states review this and have corrections, please let us know as policies regarding dental benefits continue to evolve. I look forward to hearing more about other approaches in this forum.
District of Columbia
Is there an updated/final list of EHB benchmark/plan types chosen by state?
District of Columbia
Hello Ted. We have a chart that lists the final benchmark selections for each state. The chart also includes evidence of coverage of documents and links to the CCIIO plan summaries that have been made available. Follow this link to our chart: http://www.statereforum.org/analyses/state-progress-on-essential-health-...
District of Columbia
Can someone direct me to a current listing of the states that are offering child-only plans?
Thanks,
Peggy McManus
District of Columbia
Hi Peggy - great question! This might not be as timely as you've hoped but my colleagues and I worked on a paper released late last year to identify the states that took action in response to the new federal child-only requirements. As part of this analysis, we identified 20 states where child-only policies were available as of May 2012 (the list appears on page 7 of the issue brief). Unfortunately, we did not query the states that did not take action as to whether child-only policies were available in their state and some states did not know whether child-only policies were being issued.
I have attached our paper and hope this can be somewhat helpful - you should also feel free to reach out to me directly at Georgetown's Center on Health Insurance Reforms. Thank you!!
New York
I am wondering if any states have taken steps towards fleshing out what mental health benefits might look like beyond 'outpatient and inpatient?' Taking into account, for example, assessments, intensive outpatient treatments, use of behavioral health in medical settings to help with chronic illnesses etc? Thank you in advance for any information.
Alabama
I'm very interested in the answer to this as well. I think the hope from some was that the final federal rule would get more into the specific services that would be covered, but they did not. The benchmark plans in each state give you some window into what the states expect to see covered, though some may have to be beefed up to meet the parity requirement.
I think it's also important to keep in mind that we are continuing to see the shift away from fee for service, so what specific services are covered is also likely to become moot. I think you can get a pretty good picture of what services will look like in the future by looking at how the Medical Home Models that focus on behavioral health are being implemented, particularly in Missouri.
District of Columbia
CMS has published a final rule on the ACA’s essential benefits, actuarial value and accreditation requirements.
District of Columbia
In a follow up to our blog post about how different states have been approaching the definition of habilitative benefits, Arkansas has developed some great materials on the issue. Although their conversation is ongoing, here’s their latest presentation and the draft language they’ve developed so far. AR’s Steering Committee approved language in December defining habilitative benefits to be “services provided in order for a person to attain and maintain a skill or function that was never learned or acquired and is due to a disabling condition” including “physical, occupational and speech therapy provided for developmental delay, developmental disability, developmental speech or language disorder, developmental coordination disorder and mixed developmental disorder.”
The Steering Committee has deferred to the Plan Management Committee to further define specific services to be covered under this essential health benefit.
Presentation: http://www.statereforum.org/sites/default/files/ar_habilitativejan2013.pdf
Draft Language: http://www.statereforum.org/sites/default/files/ar_draft-habilitative-se...
State Reforum Blog: http://www.statereforum.org/weekly-insight/defining-habilitative-benefits
District of Columbia
A user recently posted the following question on the Exchange Policy Decisions discussion page (http://www.statereforum.org/discussions/exchange-policy-decisions):
"I am looking for more understanding of the mandated pediatric dental benefit. If a state has a QHP that does not include dental benefits, but they offer a qualified stand alone dental plan, will an insured be required to purchase the pediatric dental benefit or does it just have to be offered on the exchange? Also, because some health plans will include pediatric dental benefits, will an adult without children have their premium adjusted (dental premium is taken out)? Thank you in advance for your time."
District of Columbia
On November 20, 2012, HHS released a proposed rule outlining Exchange and issuer standards related to coverage of essential health benefits and actuarial value.
District of Columbia
Good points, Sonya! A few thoughts.
As you rightly point out, even though the ACA limits newly eligible adults to benchmark coverage, as defined by Social Security Act 1937, "secretary-approved coverage" qualifies as a benchmark option. And a new Administration could approach this category differently than the current Administration. That said, the Bush Administration gave secretarial approval to benchmark coverage under 1937 that replicated the same coverage offered to other adults.
And you are right that, come 2017, states will need to start paying a small percentage of benefit costs for newly eligible adults. If at that juncture, it appears fiscally advantageous to trim such benefits, making such reductions is easier said than done.
On the other hand, it could be much more costly to states, even in 2017 and beyond, to provide differential benefits to newly eligible adults if that leads high-cost adults who already qualify for Medicaid (e.g., based on disability) to opt out of the newly eligible adult category. A state's ability to quantify such costs will be greatly enhanced by seeing what happens in 2014-16.
So the fiscal trade-off is as follows.
1. The advantages of giving all adults the same benefits include:
a. state savings in 2014-2016, since states would incur lower administrative costs, and states save nothing from lower benefit costs for newly eligible adults;
b. state savings both during that period and later, realized from reducing newly eligible adults' incentive to shift their coverage into a less highly renumerated category;
c. delaying the decision of whether to implement a differential benefit system until the state is in much better position to quantify the significance of factor b; and
d. delaying the implementation of any differential benefit system until a post-2014 point in time when the state will both have less on its plate and know more about CMS policy (e.g., how to distinguish the adults who should receive benchmark benefits without running a dual eligibility system that applies the state's 2009 Medicaid rules to distinguish the newly eligible from those who would have qualified under former rules).
2. The disadvantages of giving all adults the same benefits are:
a. After 2016, states will need to pay some of the increased benefit costs that result from a broader benefits package; and
b. Political factors could make it difficult for a state to save money by cutting back benefits.
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