Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,1/13/2012,#,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,1/13/2012,#,Jina Dhillon,JD,MPH,“Securing Health Rights for Those in Need”,Essential Health Benefits,Jina Dhillon“Securing Health R,1,Roadmap,Background,Overview of HHS Bulletin,Key concerns and advocacy response,RoadmapBackground,2,Background,Secretary must define essential health benefits(EHB)package,EHB must be equivalent to typical employer coverage,EHB must cover ten categories of services,ACA 1302,Background,3,Background,Ten Categories,Ambulatory patient services,Emergency services,Hospitalization,Maternity and newborn care,Mental health,substance abuse,behavioral health,Prescription drugs,Rehabilitative&habilitative,services&devices,Laboratory Services,Preventive and wellness services,chronic disease management,Pediatric,including oral&vision care,A,CA 1302(b)(1),BackgroundTen CategoriesAmbula,4,HHS Bulletin,Intended Regulatory Approach,EHB will be defined by reference to a,benchmark plan selected by each State,from following four general categories(2014 and 2015):,Largest plan in any of three largest small group insurance products*;,Any of largest State employee health benefit plans;,Any of largest three national FEHBP plan options;OR,Largest insured commercial non-Medicaid HMO,*If State does not select a benchmark,this is the default.,HHS BulletinIntended Regulato,5,HHS Bulletin,Benchmark Approach and 10 Categories,Benchmark approach intended to satisfy 1302(b)(2)(A)requiring EHB to reflect scope of“typical employer plan”,To satisfy requirement to cover all 10 categories in 1302(b)(1),State may need to supplement benchmark plan if the benchmark offers no coverage in a category of benefits*,*Most commonly non-covered categories,as identified by HHS,are habilitative services and pediatric oral and vision services.,HHS BulletinBenchmark Approach,6,HHS Bulletin,States cover costs of benefits beyond EHB,ACA requires that State must pay for mandated benefits in excess of EHB,For 2014 and 2015,if State selects benchmark subject to mandates,those mandates are part of the States EHB package and State would not have to defray those costs.,HHS BulletinStates cover costs,7,HHS Bulletin,Benefit Design Flexibility,Health plans given flexibility to offer benefits that are“substantially equal”to benefits of the benchmark plan selected by State,as modified to meet 10 categories,Health plans can adjust benefits(both specific services and/or quantitative limits)so long as they continue to cover all 10 statutory categories,HHS BulletinBenefit Design Fle,8,HHS Bulletin,Updating EHBs,ACA 1302(b)(4)(G)and(H)requires regular review and updating of EHB by Secretary,Seeking comment on how to assess enrollee difficulties with access due to coverage or cost,changes in medical evidence,or market changes.,HHS assumes the“substantially equal”standard for health plans and their annual update of benefits will reflect improvements in the quality and practice of medicine.,Planning to propose a process for evaluating benchmark process,HHS BulletinUpdating EHBs,9,Key Concerns,Lack of a Federal Minimum Standard,ACA directs,Secretary,to define,review,and update EHB package,State and insurer flexibility will result in varying packages across country,States should have flexibility to go,above,a federal floor,but not below,No insurer flexibility under any circumstances,ACA intent is to ensure comprehensive and seamless coverage,Key ConcernsLack of a Federal,10,Key Concerns,Minimizing Harm of Benchmark Framework,Benchmarks should be subject to minimum national floor of coverage,Look to Medicaid program for better benchmark options,Also promotes seamless coverage for folks transitioning between Medicaid and Exchange,Eliminate small group product option in current benchmark scheme,No benefit substitution,Key ConcernsMinimizing Harm of,11,Key Concerns,EHB should be:Typical Employer Plan,PLUS,Ten Statutory Categories,Ten categories intentionally address gaps in existing coverage,Congressional intent to transform health coverage and delivery systems,Investment in promoting health over long term,not just short-term savings,Key ConcernsEHB should be:Typ,12,Key Concerns,State Mandates,States may choose benchmarks that dont include important mandated services,Because states pay for services they require beyond the EHB,incentive for States to phase out mandates,Strongly encourage process for reviewing and including evidence-based or otherwise valuable mandated benefits,Key ConcernsState Mandates,13,Key Concerns,Harmful Utilization Management Practices,Health plans may use restrictive or discriminatory service limits,medical necessity definitions,and other utilization management policies to disrupt consumer access to necessary care,Need strong standards for medical necessity and other protections,Plans must ensu