Milestone: Decide whether to use value-based insurance design that varies patient cost sharing to correspond with clinical benefit
Value-based designs steer patients to effective treatment, but require an infrastructure to assess the evidence for effectiveness, incorporate it into the benefit structure, and update terms of coverage as evidence evolves.
*Full name: Decide whether to use value-based insurance design in Medicaid, CHIP, the basic health program, if adopted, public employee plans, or Exchange plans that vary patient cost sharing to correspond with clinical benefit.
*Relevance to the ACA:
Under the ACA, states have the authority to implement value-based benefit design in Exchanges and public programs, if they wish. In addition, the ACA employs value based benefit design in small portions of the Medicare program, and allows the Secretary to issue guidance on value-based designs by private insurers. States can decide whether to adopt value-based designs in addition or in parallel to those in Medicare and/or the private sector.
§1001 – The Secretary may develop guidelines to permit private health insurers to use value based insurance designs.
§3001, §3006, §3007, §10301 – Apply value based purchasing to hospitals, SNFs, physician fees, ambulatory surgical centers within the Medicare program.less