Essential Health Benefits and QHP
Selection Process Recommendations
Health Care Commission
September 6, 2012
www.pcghealth.com
Agenda
1. Governance Model Revision
2. Update: Exchange Timeline through January 2014
3. Essential Health Benefits Benchmark Recommendation
4. QHP Selection Process Recommendation
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Governance Model Revision
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In late 2011, the Federal government released new options for States to
consider in establishing a Health Benefit Exchange (Exchange)
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These new options, as clarified through federal rule making, allowed States to
enter into a partnership with the Federal government.
• States in a partnership could choose to retain Plan Management functions, Consumer
Assistance functions, or both. The Federal government would administer all other
functionality, most notably the large technical infrastructure to support Exchange
operations.
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Prior to the release of these new options, the Health Care Commission
carried a motion to recommend a State-based Exchange for Delaware.
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At the time of this vote, the alternatives were to cede all functionality to the
Federally-Facilitated Exchange or find other States with which to create a
regional Exchange.
Of these options, the most viable choice was to pursue a State-based model
Following the release of the Partnership model, DE re-assessed the
financial viability of all available options and determined that the StateFederal Partnership is the most appropriate choice.
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Update: Exchange Timeline
September 2012:
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Final recommendation on Essential Health Benefits benchmark submitted to
HHS
Final recommendation on Qualified Health Plan (QHP) selection process
October 2012:
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Final recommendations on all QHP policies, including certification criteria and
other standards related to plan management functionality
Final recommendations for Navigator and In-Person Consumer Assisters
certification criteria and phased approach to Outreach and Education
Continue activities to engage Consumer Assistance and Outreach partners in
planning process
November 2012:
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Finalize draft QHP process, rating criteria, and certification application
Finalize readiness checklists and training materials for Navigators and In-Person
Assisters
Submit Declaration Letter confirming Exchange model to HHS
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Update: Exchange Timeline
December 2012
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Exchange readiness review conducted by Federal government
January 2013 – March 2013
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Exchange readiness complete.
State moves forward with operational implementation of plan management and
consumer assistance functionality
March 2013
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Begin accepting QHP applications
April 2013 – October 2013
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Launch full outreach and education campaign in preparation for open enrollment
October 2013
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Open enrollment begins for QHP plans through the Exchange
January 2014
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Plan coverage year commences
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Essential Health Benefits
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The Affordable Care Act requires that any health insurance plan offered to
an individual or small business must meet certain standards.
These standards, known as essential health benefits, must cover the ten
broad categories of services listed below.
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This list applies to health insurance plans offered inside and outside of the Exchange and
represents the minimum services that must be covered. Health insurance plans may
cover additional services at their own discretion.
Essential Health Benefit (EHB) Service Categories
1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care
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Essential Health Benefits
The State has the option to choose an Essential Health Benefits
benchmark from among several options
• The three largest small group insurance products in Delaware:
• Blue Cross Blue Shield (BCBS) Exclusive Provider Organization (EPO)*
• Blue Cross Blue Shield (BCBS) Health Maintenance Organization (HMO)
• Coventry Point of Service (POS)
• The three largest state employee health benefit plans in Delaware:
• Comprehensive Preferred Provider Organization (PPO)
• HMO
• Consumer Directed Health (CDH) Gold
• The three largest federal employee health benefit plans:
• Blue Cross/Blue Shield FEHP Standard Option
• Blue Cross/Blue Shield FEHP Basic Option
• Government Employees Health Association (GEHA) Plan
*The BCBS Small Group EPO plan currently has the largest enrollment of the
small group options
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Essential Health Benefits
To support this decision, the State conducted the following stakeholder
data collection process:
• Posted analysis of benchmark options along with supporting background
material to the HCC website and issued press releases and email blasts
to spread awareness of the process
• 45 day public comment period started in June
• 2 public forums hosted in Dover to answer questions and discuss
options
• 54 attendees total for the two forums
• Received 45 written comments through the HBE Inbox and the Health
Care Commission during the comment period
• Comments received through this process are summarized on the
following slides by category
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Essential Health Benefits
Cost, Affordability, and Design
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Inclusion of only those benefits traditionally identified as necessary to compromise a group
market-accepted program. Benefits other than those mandated by DE law, and those not included
in most common DE employers plans should not be included.
Inclusion of quantitative limits (visit/day limits/per procedure limits) wherever appropriate
Additional benefits should utilize treatment limitations to maintain affordability
Plan should not have excessive cost-sharing requirements to protect consumers from unexpected
financial obligations
Allow maximum flexibility regarding actuarially equivalent substitutions within benefit categories,
and provide clarity indicating how and under what circumstances substitutions may be made
Ensure that plans do not utilize benefit design flexibility to discriminate against vulnerable, highcost consumers
Allow flexibility in plan design and permit substitutions, continue to allow insurers to use
appropriate care management and health promotion tools
Work with insurers to manage the product and rate filing process
Consistency in design through 2015
Establish clear and meaningful standards for comparing QHPs to the benchmark plan
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Essential Health Benefits
Chronic Disease
Cancer
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Access to oral and IV administered chemotherapy, stem cell transplant and radiation therapy.
Equal treatment of patients receiving IV, injectable, and/or orally administered treatments
Coverage for treatment at National Cancer Institute (NCI) cancer centers
Prescription drug benefit that offers full coverage of 6 protected classes (>1 per class)
Balanced coverage and affordable access for all aspects of cancer treatment: preventive care to
diagnostic tests to treatment options (targeted therapies, palliative care, hospice)
Monitor the use of tiered networks that may discriminate against specialty drug needs
Breast cancer screenings for women and men
Multiple Sclerosis
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Access to inpatient hospital services without caps for people with chronic illnesses
Protections from discrimination against specialty medications placed on a fourth, or specialty tier
with different cost-share structure
Allow for the number of physical therapy visits to be determined by physical therapist or patient’s
doctor, rather than having a predetermined limit
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Essential Health Benefits
Chronic Disease cont.
Hemophilia
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Access to specialists at federally recognized hemophilia treatment centers (HTCs)
Access to full range of FDA approved clotting factor products
Access to range of specialty pharmacy providers
“Medical necessity” should not be defined by insurers, but determined by physicians in
conjunction with the patient.
Coverage for screening of von Willebrand Disease in cases of women with menorrhagia
Cardiovascular Disease
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Cardiac rehabilitation, diabetes screening and self management, nutrition counseling, and
smoking cessation
Continued monitoring of adequacy and quality once EHB plan is implemented
Disabilities
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Coverage of assistive technology, home health and personal care services, and medical transport
Culturally sensitive outreach materials that meet the needs of those with specific disabilities
Consideration of medical expenses when determining income guidelines for health exchange
Easily accessible healthcare facilities, offices, and equipment for patients with disabilities (exam
tables, scales and radiological machines, etc)
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Essential Health Benefits
Children
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Early Periodic Screening Diagnosis and Treatment (EPSDT) is the most appropriate benefit
package for children based on children’s clinical needs
Inclusion of oral and vision care in the Pediatric Services benefit
Inclusion of pediatric and dental benefits that are primarily preventive or screening services
Inclusion of non-cost considerations in establishing EHB – investments in children through
preventive services, screenings, etc that reduce health care spending over long term
“Medical necessity” requirements found in the Medicaid program are most appropriate definition
for children
Coverage for in-home personal care, mobility-related devices and other durable medical
equipment
Age not to be used as basis for limiting services
Utilize small employer model for pediatric oral health services benchmark
Broad access to all dental plans offering the required benefits and meeting qualification standards
inside the Exchange
Coverage for medical food and formula for children affected by Phenylketonuria (PKU)
No limits on visits to physical therapy, occupational therapy, speech therapy
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Essential Health Benefits
Women and Reproductive Health
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Robust coverage of pregnancy and maternity benefits such as preconception care, prenatal, labor
and delivery, postnatal, postpartum care, breastfeeding, and mental health for postpartum
depression.
Coverage of habilitative services to cover early intervention services for premature infants and
other children with special health care needs
Coverage for gynecological visits, lab testing, as well as indicated treatment for infections
Coverage of assisted reproductive technologies and voluntary sterilization for men and women
Screenings, counseling, and treatment for all STDs for men and women
Hospice and Palliative Care
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Coverage of hospice and palliative care
Preventive Care
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Coverage of tests and services needed to prevent, detect and treat the early onset of disease
Exclusion of expensive benefits that only impact a few
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Essential Health Benefits
Behavioral Health
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Inclusion of strong mental health benefits – Mental Health Parity and Addiction Equity Act covers 8
diagnoses of serious mental illness (SMI), with addition of substance use disorders (SUDs)
Robust and routine outpatient benefits for mental health and substance abuse services
Support of inpatient hospital services for acute mental illness, medically supervised detox,
psychotropic and addiction medications, behavioral therapy, habilitation and rehab services,
screening, education and self management, intensive case management and ACT teams, peer
support services, SBIRT: Screening, Brief Intervention and Referral to Treatment
Screening for mental disorders in primary health care, across the life span and in connection to
treatment and support systems
Prescription Drugs
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Assure provider and patient choice of medicines
Do not impose “one drug per class” rule for it may not meet patient’s clinical needs, and is likely to
lead to discriminatory benefit designs
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Essential Health Benefits
Chiropractic Services
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Inclusion of chiropractic network and services found to increase the health of the general
population, score high on patient satisfaction and proven cost effective.
Dietician/Nutritional Services
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Coverage of Medical Nutrition Therapy (MNT) by Registered Dietitians and Licensed Dietitian/
Nutritionists
Exclude pre-authorization or medical review requirement (beyond physical referral) for MNT
Inclusion of unlimited number of visits with a Registered Dietician for children and adults
• Alternative: minimum of 6 visits with an RD/LDN per condition per year, with additional visits
as needed with physician referral
Adequate nutrition coverage, allowing for proactive treatment of disease conditions such as
diabetes, hypertension, and obesity
Coverage for home infusion including enteral nutrition support (tube feedings)
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Essential Health Benefits
Which plan is the best fit for stakeholders?
• 6 stakeholders specified a plan option in their comments, the majority
of which support the BCBS small group option:
1.
2.
3.
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6.
Either BCBS option under Small Group Plans
BCBS Standard and the BCBS Basic Plans (federal plans)
BCBS small group
BCBS Small Group or State Employee Plans
Least expensive BCBS small group plan
BCBS Small Group HMO Plan + FEDVIP for pediatric
• Some concerns mentioned are not possible under current guidance
(requiring EPSDT, restricting cost sharing, broadening provider
networks, requiring services that are not included in any benchmark)
• The small group plans are also the least expensive options in terms of
premium. Among the small group options, premiums are comparable.
• Small group and State Employee benchmarks cover all insurance
mandates passed before December 2011.
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Essential Health Benefits
Recommendation: Based on stakeholder feedback received, the BCBS
Small Group EPO plan option should be Delaware’s benchmark plan
for the individual and small group market in 2014 and 2015.
This recommendation will be supplemented to provide EHB categories
such as pediatric dental/vision and habilitative services once final
guidance has been issued by HHS on supplement options.
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QHP Selection Process
The State has two options to select health plans for inclusion in the
Exchange
• Select health plans through a procurement-style process (otherwise
known as selective contracting):
1. State issues an RFP.
2. Health plan issuers respond with their product and pricing details.
3. State chooses plans from the pool of applicants for inclusion in Exchange.
• Select health plans through a certification process:
1. State sets certification standards for qualified health plans.
2. Health plan issuers submit product and pricing information for review.
3. State reviews plans to ensure that certification, pricing, and accreditation
standards are met.
4. Plans that meet all criteria are included in the Exchange.
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QHP Selection Process
CCIIO has stated that, for States participating in the full FFE, the
federal government will pursue a certification process using the federal
minimum standards.
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There will also be two multi-State plans chosen by the federal Office of
Personnel Management (OPM) offered on every Exchange
OPM plans will be certified using the same process and criteria as the
FFE
Recommendation: The State pursue a certification process for the
Exchange
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Certification standards will likely include provisions that go beyond the
federal minimum to ensure that Delaware’s insurance market is
protected from adverse selection while contributing to the
achievement of the State’s health care goals.
Final recommendations on certification standards will be presented
during the October Health Care Commission meeting.
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