Essential health benefits and people with disabilities final


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

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  • Report on meeting with CMS – very briefly, HDA, states that we work with and health care policy and advocacy groups identified a major flaw in the proposed rules around Medicaid eligibility for people with disabilities who have earnings above 100% of fpl and below 138% of fpl. Trapped in the Adult Group – good news, is that CMCS has really listened to our comments and is working with us and others to identify solutions.
  • HHS kind of punted…states have to look at both the Medicaid expansion benchmark plan and the private insurers exchange products – does a lack of guidance from the Feds damage the state’s negotiating power with private insurance companies around things like scope, duration and out of pocket? Will the power of private insurance industry to define these services categories drive what ends up in EHB? It kind of defeats the original purpose of building a health care delivery system with EHB…And of course all of this happening with the back drop of extreme fiscal pressure on states to cut Medicaid and state expenditures on health care for their employees… THIS IS WHY YOU NEED TO BE VOCAL
  • Lisa – can you do this slide – these are our concerns around insurers
  • Experiences with Part D should be an example – we learned the hard way that without strong guidance plans will cover services but ask for 100% OOP. We remedied that, but after a lot of people went without therapeutic drugs they needed.What kind of flexibility will there for individuals to switch between plans?
  • Provide definition that NAIC uses; talk about parity and Prescription Drugs – this easy to find, Part D plans are on line and easy to access, private insurance plans have experience with this
  • Essential health benefits and people with disabilities final

    1. 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? 1
    2. 2. Overview &Strategies for Moving Forward Health & Disability Advocates
    3. 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) 3
    4. 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 4
    5. 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 5
    6. 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 6
    7. 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. 7
    8. 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 8
    9. 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 9
    10. 10. States Have a Lot of Decisions to Makein 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 10
    11. 11. States Have a Lot of Decisions to Makein 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? 11
    12. 12. Concerns About Too Much Flexibility forPrivate 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 12
    13. 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 13
    14. 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 14
    15. 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 15
    16. 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?). 16
    17. 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. 17
    18. 18. Please let us know if you have a question by eitherraising your hand OR typing in a question tothe presenters. Remember, if you would like tospeak, we can not un-mute your line UNLESS youhave entered your “audio PIN” which was given toyou at the start of the call. Health & Disability Advocates 18