Companion PowerPoint to presentation by Health & Disability Advocates on Essential Health Benefits on January 30, 2012

1. Welcome/Call Objectives
 Objective 1: Update on Policy and Advocacy work around
Medicaid Eligibility for people with significant health care
needs post-2014
 Objective 2: Provide an overview of what health care
services and supports (known as Essential Health Benefits)
will be a part of the new Medicaid Expansion group plans
and Health Insurance Exchange insurance products
 Objective 3: Discussion about opportunities to influence
the development of Essential Health Benefits at the state
level
 Objective 4: What information or tools are needed to
ensure that people with disabilities are not under-insured
after 2014 because of decisions around Essential Health
Benefits?
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2. Overview &
Strategies for Moving Forward
Health & Disability Advocates

3. Background
 Patient Protection and Affordable Care Act (ACA)
requires:
 All qualified health plans to provide “Essential Health
Benefits (EHB)” by 2014 (all non-grandfathered plans in
individual and small group market, Medicaid
benchmark and benchmark equivalent, and Basic
Health Programs)
 Health & Human Services (HHS) to define EHB in
§1302(b) – does not specify how it must be defined (i.e.
does not require regulation)
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4. Background (cont)
 §1302(b)(1) of the ACA says that EHB must include:
 Ambulatory Patient Services
 Emergency Services
 Hospitalization
 Maternity and Newborn Care
 Mental Health and Substance Abuse Treatment
 Prescription Drugs
 Rehabilitative and Habilitative Services and Devices
 Laboratory Services
 Preventative and Wellness Services and Chronic Disease
Management
 Pediatric Services, Including Oral and Vision Care
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5. HHS Bulletin on EHB
 HHS issued a bulletin on 12/16/2011 outlining their
intended approach to defining EHB:
 No federal standard and no federal definitions
 States can choose between different plans as
“benchmarks” on which to base their EHB plans (more
detail in next slide)
 States must cover all the categories outlined in
§1302(b)(1) even if not covered in the benchmark they
select
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6. HHS Bulletin: Benchmark Plans
 HHS intends to propose that states can choose
between the following for their benchmark plans:
 The largest plan by enrollment in any of the three largest
small group insurance plans
 Any of the largest three State employee health benefit
plans by enrollment
 Any of the largest three national FEHBP plan options by
enrollment
 The largest insured commercial non-Medicaid HMO
operating in the state
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7. HHS Bulletin (Cont)
 Insurer Flexibility: Health insurance issuers will have
flexibility to adjust benefits, including both the specific
services covered and any quantitative limits, so long as they
continue to offer coverage for all 10 statutorily-mandated
EHB categories. The flexibility is subject to the baseline set
of benefits as reflected in the benchmark plan selected.
 State Mandates: If the state chooses an option (small
group, HMO, or state employee) that includes state
mandates, those will be included in EHB during 2014-15.
 If the state chooses a benchmark plan that does not include
the states’ benefit mandates (for example a FEHBP plan that
does not cover some or all of the states’ benefit mandates),
the state must cover the cost of those mandates outside of
the EHB package.
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8. Concerns for
People with Disabilities
 Lack of transparency/data
 Impossible to determine in most states:
 Which plans will qualify as potential benchmarks?
 What is covered/out-of-pocket cost information for those
plans (proprietary information)?
 Lack of a federal definitions on scope, duration and
cost-sharing for the following:
 Rehabilitation & Habilitation Services
 Medical Necessity
 Durable Medical Equipment
 Prescription Drug Formularies
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9. Definitions of Rehabilitation &
Habilitation:
 National Association of Insurance Commissioners
defines Rehabilitation and Habilitation like this:
 Rehabilitation: “health care services that help a person
keep, get back or improve skills and functioning for daily
living that have been lost or impaired because a person
was sick, hurt or disabled”
 Habilitation: “health care services that help a person
keep, learn or improve skills and functioning for daily
living.”
 Two are intrinsically linked – parity between the two
services is important
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10. States Have a Lot of Decisions to Make
in Tough Fiscal Times:
 Without strong guidance from HHS on scope, duration
and cost-sharing for services how will states determine
which benchmark model and services will best meet the
needs of people with disabilities?
 From what is known of private small business plans:
 Limits on Rehabilitation with restoration of functioning as a
goal and if individuals are not able to show progress, or bump
up against a limit on duration of service;
 No habilitation services;
 Limits on drug formularies and high cost-sharing on
therapeutic drugs;
 No coverage of DME or extremely high cost-sharing
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11. States Have a Lot of Decisions to Make
in Tough Fiscal Times:
 How will states even know if individuals in the
benchmark plan (either in Medicaid Adult Group or an
exchange insurance product) have disabling
conditions where they need more supports?
 Who will determine what is a medical necessity if
there is no guidance from HHS?
 Other?
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12. Concerns About Too Much Flexibility for
Private Insurers:
 Requires health plans to be “substantially equal” to the
benefits of the benchmark selected by the state
 Insurers will have flexibility to adjust benefits,
including both the specific services covered and any
quantitative limits, provided still cover all categories
 HHS is considering whether to allow insurers to
substitute across the benefit categories
 Flexibility in prescription drugs: must cover categories
and classes in benchmark plans but plan can choose
specific drugs within those categories or classes
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13. Concrete Recommendations:
 Benchmark plans should adopt Medicaid or NAIC
definitions of Rehabilitation & Habilitation
 If benchmark does not include these definitions HHS
should require:
 Parity with rehabilitative services – if cover PT, OT, and ST for
rehabilitation must also cover those for habilitation
 Transitional approach where plan decide which services to
cover and report
 Benchmark plans need to address how they will
manage chronic conditions
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14. Concrete Recommendations:
 HHS should provide more guidance on state mandates:
 Current bulletin allows states to include mandates without paying
for them for two years. What happens after that?
 Benchmark plans need clear guidance on scope & duration of
benefits.
 For example, will the benchmark plan offer services like Personal
Attendant Services (PAS) under the Rehabilitation category?
 Benchmark plans need limits on what cost-sharing should be
incurred.
 For example, limits on cost-sharing for Rehabilitation services like
PAS and Durable Medical Equipment (DME).
 HHS should provide a definition of medical necessity and tie
services to evidenced based research and practices
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15. Strategies for Moving Forward:
 Where are opportunities for influencing decisions
about Essential Health Benefits at the state level:
1. Push for the adoption of National Association of
Insurance Commissioners definitions of Rehabilitation
and Habilitation;
2. Recommend that there be parity between
Rehabilitation and Habilitation in benchmark plans;
3. Advocate for no limits on benefit-specific services
and/or condition-based exclusions – medical necessity
based on evidenced based research should drive
coverage
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16. Strategies for Moving Forward:
 Where are opportunities for influencing decisions
about Essential Health Benefits at the state level:
4. Prescription Drugs: Standard of two drugs per
Therapeutic Class and adopt the Part D Patient
Protection Clause; and
5. Facilitate some thinking around how state mandates
can work in the benchmark, model potential
populations covered and evaluate how to get value out
of including state mandates (does it relieve $ in other
areas of the health delivery system?).
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17. Strategies for Moving Forward:
 Use the experience of administering the Medicaid
Buy-in programs to help identify utilization of services
like Rehabilitation and Therapeutic drugs to help
frame the potential needs of persons with health care
needs in this economic bracket (100% - 138%) for
discussions around Essential Health Benefits for
benchmark plans; and
 Continue advocacy for the role of the Medicaid Buy-in
programs in the post-2014 health care delivery system.
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18. Please let us know if you have a question by either
raising your hand OR typing in a question to
the presenters. Remember, if you would like to
speak, we can not un-mute your line UNLESS you
have entered your “audio PIN” which was given to
you at the start of the call.
Health & Disability Advocates
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