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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District of Columbia
A webinar listener asked: This question is about the distinction between a plan versus a product. Will the benchmark plan have to be more specific with cost-sharing? Can you outline what this issue is and what it means in Oregon?
Oregon
We are trying to be very clear that our EHB designation is focused on the contents or benefits inside of a health plan. We have not touched on the cost-sharing requirements in any way. This was our base and our insurance division was moving on from there and we’ve had some legislation that wants to set some very common features to cost-sharing so that a person can compare bronze to bronze, etc. We wanted to set our standards for content of the benefits and we have assumed cost-sharing will rap around that inside the Exchange. We did not get into deductibles and copays as we did our analysis - that was off of the table.
Nevada
This has not come up in Nevada. There was plenty of public comment and concerns raised about deductibles, coinsurance and copays. One of our richest EHB plans is actually the leanest when it comes to cost-sharing because it’s a high deductible health plan. There has been discussion about riders, and which items were missing in what categories and what plans needed a rider. I think we’ve included all of that information in our report, but we didn’t really focus on that. This was mostly about helping the public understand the difference between benefits and cost-sharing under the EHB.
District of Columbia
A webinar listener asked: How many states have recommended benchmarks that don’t include mental health benefits? For the states that do not, how have they supplemented their benchmarks?
District of Columbia
We’ve had a chance too look into what recommended plans states have chose and what their mental health benefits included. They were fairly inconsistent. Out of the eleven states that have chosen benchmarks, there was no state that provided no mental health coverage, but some states did not offer substance abuse treatment. There was a lot of range within the mental health benefits. Some only offered outpatient services and no inpatient. There were different kinds of approaches to mental health. We can try to share our notes about this on the site, especially once more state decisions are available.
District of Columbia
A webinar listener asked: The EHB bulletin included a “one drug per class” standard. Are some states considering a more robust plan? What is Oregon considering? And related to that is a question about how you are handling drug cocktails, considering this bulletin?
Oregon
I think at this point we’ve heard that we can use the benefit design of our choice as long as there was at least a minimum of one drug per class, but that this did not necessarily mean that that was the entire limit associated with the bulletin. Regulations have yet to evolve in terms of how that will be handled. We have proceeded to choose the prescription drug plan associated with the benchmark plan and that sets the minimum they must cover. I don’t think that defines the extent of what the prescription benefit will be – advocates would be very concerned if there was only one choice.
Nevada
We were on a call with federal officials about a month ago and they indicated that they were moving away from what was in the bulletin and will require that each qualified health plan provide a number of drugs that is essentially equivalent to the benchmak plan's number of drugs offered in each class. That has us concerned because it will be that much more difficult to regulate. The other issue is that we have formularies that do not cover any off-formulary drugs at all. You can get them at the network discounted rate but there is no credit given towards your deductible. Two of the plans actually cover all drugs that are non-forumlary, just at a higher cost-sharing rate. They basically cover all drugs. This is a question we need more guidance from federal officials on.
District of Columbia
A webinar listener asked: Jon – you mentioned a side-by-side analysis that was performed for some of different benchmark plan options that was part of your state’s analysis. Is this analysis available for public review?
Nevada
Yes, it is available at: http://exchange.nv.gov/Meetings/Nevadas_Essential_Health_Benefits/. There is a letter to Commissioner Kipper that recommends the three plans identified by the board. The “Essential Health Benefits Report” provides a description of the process we went through and the “Benchmark Plan Comparison” is “Attachment B” to that. We show that we compared physical therapy, occupational therapy, speech therapy, skilled nursing facilities, rehabilitation, hospital, home health care, durable medical equipment, etc. It’s a fairly extensive comparison.
District of Columbia
A webinar listener asked: Does the Medicaid benchmark apply to all Medicaid enrollees or just the newly eligible as states move forward with the expansion?
Oregon
No, this just applies to the newly eligible population. The categorically eligible and traditional Medicaid populations will not be subject to any changes at all. It is only the newly eligible from 0 to 133% FPL that are affected by this benchmark.
District of Columbia
I agree that only the new expansion of adults would be required to be in a Medicaid benchmark plan, but under the Deficit Reduction Act of 2006, states also have the option of providing a benchmark package to some other Medicaid recipients. This does not include all, but for example low income parents do fall into this category among others.
District of Columbia
A webinar listener asked: What is the difference between rehabilitative and habilitative services? Jon – you talked about the habilitative conundrum. Can you address this difference in definitions?
Nevada
Rehabilitative describes a service that gets you back to a former state. For instance, say you had a certain level of functioning and were in a car accident. Rehabilitative services get you back to the state of wellbeing you were at prior to that accident. Habilitative services - notice there is no “re” on the beginning of the word - gets you to a functioning state that you were not at prior to treatment because it’s usually for a disease state that you have. The goal of habilitative services is to get you to a level of functioning where you can function on your own for the first time. They cover autism, cerebral palsy, or diseases where you did not have that function to begin with.
District of Columbia
A webinar listener asked: What will happen to standards set by EHB definitions if there is a change in the Presidential Administration? Would a new President have to enforce the minimum level of coverage set by the EHB? Is this something the states are thinking about?
Nevada
It’s difficult to play all the “what if” games and difficult to say what might be repealed or changed. Unless the law is repealed or changed or the regulations are changed, we must comply with the current laws and regulations. If a state does not comply, it is subjecting itself to lawsuits.
Oregon
Here in Oregon, the situation is similar. We’re proceeding and will have to see how things progress. The timing is such that we need to go with the law of the land at the moment.
District of Columbia
A webinar listener asked: Are states addressing the issues of mobile workers that move between states including farmer and construction workers. What happens when a plan moves across state lines between Washington and Oregon and the two states have different EHB definitions?
Oregon
I think we are trying to consider this. There have been conversations on how to align across borders, not just for benefits but health information as well. Everyone is very focused on getting the exchanges up and running in our own states, but these issues that are going to need more time and consideration.
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