NHC Essential Health Benefits Recommendations
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NHC Essential Health Benefits Recommendations



The National Health Council conducted research, did an analysis, and prepared proposed regulatory language to assist the Secretary of Health and Human Services with the preparation of an essential ...

The National Health Council conducted research, did an analysis, and prepared proposed regulatory language to assist the Secretary of Health and Human Services with the preparation of an essential health benefits (EHB) package that will serve the needs of people with chronic diseases and disabilities. This slide show is from a NHC briefing on EHB, given August 3, 2011.



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NHC Essential Health Benefits Recommendations NHC Essential Health Benefits Recommendations Presentation Transcript

  • A United Patient Voice on Essential Health Benefits Marc Boutin Executive Vice President & COO National Health Council August 3, 2011
  • The mission of the National Health Council is to provide a united voice for people with chronic diseases and disabilities.
  • Potential Approaches to Developing the Essential Health Benefits Package 1 2 3
    • 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
  • Essential Health Benefits Landscape
    • 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
    IOM DOL HHS + State Exchanges Health Plans Informing Regulations Developing Regulations Implementing Regulations
  • Timeline for Engagements: Essential Health Benefits 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 March 2011 May July September November January 2012
  • 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
  • Regulatory Opportunities
  • Non-Discriminatory Utilization Management 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. 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
  • Continuity of Care Protections 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. 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
  • Cost-Sharing Protections 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. 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
  • State Navigator Programs 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. 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
  • Plan Premium Costs *The estimated premiums and the reduced OOP max for the platinum plan are actuarial estimates from ARC. Plan Estimated 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
  • Care Coordination & Management Activities 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. 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
  • Medical Necessity Decision Making & Appeals 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. Recommendation 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
  • State Exchange Requirements 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. 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
  • Regulatory Opportunities
  • Marc Boutin Executive Vice President & COO National Health Council [email_address]