Defining Essential Health BenefitsDelaware Health Care Commission

June 7, 2012

www.pcghealth.com

Agenda

1. Review of Federal Guidance

2. Identification of Benchmark Plans

3. Summary of Options Analysis

4. Stakeholder Input Strategy

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Federal Guidance – 10 Broad Categories

• Ambulatory services

• Emergency services

• Hospitalization

• Maternity and newborn care

• Mental health and substance use disorder services, including behavioral health treatment

• Prescription drugs

• Rehabilitative and habilitative services and devices

• Laboratory services

• Preventive and wellness services and chronic disease management

• Pediatric services, including oral and vision care

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Federal Guidance - State Mandates and Scope

• State Mandates• If there are State mandates that fall outside of the EHB package, the

State would be required to “defray” the costs of those benefits for Exchange plans.

• Originally, the goal was to prevent federal dollars from subsidizing coverage of State mandates in the Exchange.

• We need more specifics on how this would work logistically.

• How do the “metallic” plan levels fit into this analysis?• Short Answer: They don’t. All plans will need to cover the same EHB

package.

• EHB doesn’t deal with cost sharing, metallic level doesn’t come into play

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Federal Guidance – Benchmark Approach

• Benchmark Approach• One of three largest small group plans by enrollment

• One of three largest State employee plans by enrollment

• One of three largest Federal employee plans by enrollment

• Largest HMO by enrollment

• Benchmark plans may be supplemented by plans that cover, for example, pediatric dental and vision, as most small group plans will not meet that criteria

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Effect on Current Plans

• All plans in the individual and small group market will be required to offer “substantially equal” benefits to the benchmark• Plans will have flexibility to adjust some specific services and

quantitative limits as long as the plan has the same overall value as the benchmark

• By choosing a plan that is subject to all state mandates, the state would guarantee that all current mandates are included

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Delaware Benchmark Options

• The State has the option to choose a benchmark plan from among several current plans:• The three largest small group insurance products in Delaware:

• Blue Cross Blue Shield (BCBS) Exclusive Provider Organization (EPO);• Blue Cross Blue Shield (BCBS) Health Maintenance Organization (HMO);

and• Coventry Point of Service (POS).

• The three largest state employee health benefit plans in Delaware:• Comprehensive Preferred Provider Organization (PPO);• HMO; and• Consumer Directed Health (CDH) Gold.

• The three largest federal employee health benefit plans:• Blue Cross/Blue Shield FEHP Standard Option;• Blue Cross/Blue Shield FEHP Basic Option; and• Government Employees Health Association (GEHA) Plan.

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High Level Options Summary

• Small Group Plans• All State mandates are covered• Represents typical small employer plan for the State

• State Employee Plans• Broader infertility coverage• No quantitative limits on physical, occupational, and speech therapy• Higher limits for home health services than small group plans• Broader mental health coverage than small group plans

• Federal Employee Plans• Broader maternity coverage• Higher limits on therapies than small group plans• Broader mental health coverage than State Employee plans

• US Preventative Services Task Force—Schedule A & B Benefits• http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm

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Stakeholder Input Strategy

• Open comment period• Analyses of plan coverage and reference information will be made

public for stakeholder review.• Stakeholders will have the opportunity to submit written comments

regarding the benchmark options. • During the open comment period, a statewide forum will be held to

discuss questions and clarify issues.

• Recommendation• All stakeholder input will be organized and analyzed to ensure

appropriate consideration in the benchmark plan decision.• The Health Care Reform Steering Committee will issue a

recommendation to the Health Care Commission for review.

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Exchange Information

The Delaware Health Benefit Exchange Program will soon post to the HCC website additional background and research information used to support Exchange planning and development activities

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