Post on 13-Dec-2014
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A United Patient Voice onEssential Health Benefits
Marc BoutinExecutive Vice President & COO
National Health Council
August 3, 2011
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The mission of the National Health Council is to provide a united voice for people with chronic diseases and disabilities.
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Potential Approaches to Developing the Essential Health Benefits Package
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Define benefits narrowly
Medicare Part B program
Define categories of benefits broadly and establish process-oriented requirements as a ‘check’ on plans
Medicare Part D program
Define categories of benefits broadly, granting plans the flexibility to develop coverage policies within each category
FEHBP plan
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Essential Health Benefits Landscape
IOM DOL HHS+ State Exchanges
Health Plans
Informing Regulations Developing Regulations Implementing Regulations
Promote robust, transparent oversight process at the federal and state levels
Develop a more granular understanding of the services that are considered essential and the cost impact of those services
Continue to endorse NHC’s values on EHB
Ensure that any limitations to DOL’s database are addressed
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Timeline for Engagements: Essential Health Benefits
March 2011 May July September November January 2012
Proposed Rule Anticipated from HHS
IOM Committee Meeting
IOM Recommendations Expected
DOL data expected in “Spring”
Third and fourth IOM Committee meetings
Develop essential health benefits package using FEHB plan as foundation in consultation with NHC members
Develop ideal approach for HHS/State regulatory oversight
Vet regulatory approaches with NHC members
Share regulatory approach with HHS
Commission actuarial analysis of the affordability of NHC’s essential health benefits package and discuss implications among membership
Craft regulatory language that HHS could adopt and review with NHC membership
Craft regulatory language
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Development of Policy Recommendations
EHB White Paper
• This report established baseline knowledge and considered the approaches HHS may take in defining the EHB package
EHB Cost Analysis
• This analysis examined the cost of a comprehensive health benefits package, using the Federal Employees Health Benefits Package as a model
EHB Policy Recommendations
• This report will articulate NHC’s recommendations and proposed solutions and will be shared with key policymakers and stakeholders
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Regulatory Opportunities
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Non-Discriminatory Utilization Management
Recommendation HHS Regulatory Opportunity
EHB regulation should provide for oversight of plan benefit design to avoid discrimination caused by unfair utilization management techniques
Outline oversight mechanisms for states to use in reviewing plan utilization management policies
States should establish oversight mechanisms to review plan processes
HHS should continue to monitor state oversight programs to guarantee that plans are meeting federal requirements
MODEL PROGRAM: The Medicare Part D Formulary Review process analyzes the use of practices such as prior authorization, step therapy, and quantity limits and compares practices to industry standards, guidelines, and other Part D plans.
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Continuity of Care Protections
Recommendation HHS Regulatory Opportunity
EHB regulation should include patient protections to ensure plan cooperation and coordination when people switch enrollment between plans
Include protections for patients switching enrollment (among qualified health plans and to and from Medicaid) so patients do not have to re-establish the necessity of treatment protocols already in place
Require plans to provide written notice of the right to transfer treatment protocols
Require Navigator education programs to provide information about the potential implications of switching between plans
MODEL PROGRAM: Medicare Part D Auto and Facilitated Enrollment processes ensure beneficiaries with limited income remain enrolled in Part D plans that have reduced costs.
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Cost-Sharing Protections
Recommendation HHS Regulatory Opportunity
EHB regulation should require plans to have non-discriminatory cost-sharing policies across benefit categories.
Exchanges should allow creative benefit design to encourage plans to develop novel approaches to cost- sharing
Require plans to disclose the deductible, co-payment, and co-insurance amounts applicable to covered services prior to enrollment
Prohibit specialty tiers
Offer protection from high out-of-pocket costs on prescription drugs and allow tiering exceptions
Create oversight mechanisms to ensure that states are reviewing plan benefit design to ensure cost-sharing is neither unfair nor discriminatory
MODEL PROGRAM: The Maryland Comprehensive Standard Health Benefit Plan* specifies cost-sharing requirements for certain services and includes some service limits to offer an extra level of patient protection for enrollees in these plans.
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State Navigator Programs
Recommendation HHS Regulatory Opportunity
EHB regulation should contain specific mechanisms to assist patients in identifying an appropriate plan and navigating enrollment and other key plan processes
Include resources to educate enrollees about their plan rights and responsibilities
Prohibit educational materials and programs from steering or attempting to steer people into a plan or type of plan
Navigator programs should coordinate with other consumer assistance programs in the state
MODEL PROGRAM: The State Health Insurance Assistance Programs (SHIPs) are an often cited example of what a Navigator program could resemble. SHIPs provide assistance to Medicare beneficiaries and help them with their Medicare benefits.
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Plan Premium Costs
PlanEstimated
Annual Premium—Individual*
OOP Maximums Total Cost
BCBS Model $5,032
Platinum $5,205 $1,500 $6,705
Gold $4,627 $5,950 $10,577
Silver $4,048 $5,950 $9,998
Bronze $3,470 $5,950 $9,420
*The estimated premiums and the reduced OOP max for the platinum plan are actuarial estimates from ARC.
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Care Coordination & Management Activities
Recommendation HHS Regulatory Opportunity
EHB regulation should require proven effective care coordination and management activities to improve outcomes and reduce total healthcare costs
Require care coordination activities as an essential health benefit
Create pathways for plans to develop innovative strategies to compensate providers for effective care coordination
Encourage state IT programs to include information about the care coordination policies of plans on state Exchange websites
MODEL PROGRAM: Medicare Advantage coordinated care plans are required to have quality improvement and chronic care improvement programs as well as monitor and evaluate these activities and outcomes.
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Medical Necessity Decision Making & Appeals ProcessesRecommendation HHS Regulatory Opportunity
EHB regulation should outline clear, understandable standards for plan medical necessity determinations and should include a process for appealing adverse plan determinations
Require plans to use medical necessity criteria that are objective, clinically valid, and compatible with generally accepted principles of care
Plan denials based on lack of medical necessity should explain, in clear language, the criteria used to make the determination
Create uniform exceptions and appeals process for items and services that do not meet definition of medical necessity
Navigator programs should be available to guide patients through the complexities of plan appeal processes
MODEL PROGRAM: Medicare Part D offers an example of a federally regulated, nationwide program that has set requirements of participating plans for exceptions and appeals processes.
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State Exchange Requirements
Recommendation HHS Regulatory Opportunity
HHS Exchange regulation should include federal and state oversight to ensure that plans offered on state exchanges meet all appropriate and necessary criteria (including network adequacy standards)
Require Exchanges to monitor and seek to improve quality of care
Plans may not exclude eligible individuals from coverage
Plans utilizing a provider network shall be required to demonstrate an adequate number of in-network providers in various specialties corresponding to the EHB categories of services
MODEL PROGRAM: The Massachusetts Health Connector’s Commonwealth Choice program offers a variety of plans with different benefit packages. The Health Connector reviews and approves each plan offered in Commonwealth Choice. Of the two operational health insurance exchanges (MA and UT), the program in Massachusetts provides more oversight and patient protections than the exchange in Utah.
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Regulatory Opportunities
Marc BoutinExecutive Vice President & COO
National Health Councilmboutin@nhcouncil.org