NHC Essential Health Benefits Recommendations

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 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Essential Health Benefits Landscape ,[object Object],[object Object],[object Object],[object Object],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 ,[object Object],EHB Cost Analysis ,[object Object],EHB Policy Recommendations ,[object Object]

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 ,[object Object],[object Object],[object Object]

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 ,[object Object],[object Object],[object Object]

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 ,[object Object],[object Object],[object Object],[object Object]

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 ,[object Object],[object Object],[object Object]

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 ,[object Object],[object Object],[object Object]

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 ,[object Object],[object Object],[object Object],[object Object]

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) ,[object Object],[object Object],[object Object]

Marc Boutin Executive Vice President & COO National Health Council [email_address]

NHC Essential Health Benefits Recommendations

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