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Welcome/Call ObjectivesObjective 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?

Essential Health Benefits and People with Disabilities

Overview &Strategies for Moving Forward

Health & Disability Advocates

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BackgroundPatient 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)

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Background (cont)§1302(b)(1) of the ACA says that EHB must include:

Ambulatory Patient ServicesEmergency ServicesHospitalizationMaternity and Newborn Care Mental Health and Substance Abuse TreatmentPrescription DrugsRehabilitative and Habilitative Services and DevicesLaboratory ServicesPreventative and Wellness Services and Chronic

Disease Management Pediatric Services, Including Oral and Vision Care

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HHS Bulletin on EHBHHS 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

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HHS Bulletin: Benchmark PlansHHS 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

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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.

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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 ServicesMedical NecessityDurable Medical EquipmentPrescription Drug Formularies

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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

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States Have a Lot of Decisions to Make in 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

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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?

States Have a Lot of Decisions to Make in Tough Fiscal Times:

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Concerns About Too Much Flexibility for Private 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

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Concrete Recommendations:Benchmark plans should adopt Medicaid or

NAIC definitions of Rehabilitation & HabilitationIf 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

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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

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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

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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?).

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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.

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DiscussionPlease let us know if you have a question by either raising your hand OR typing in a question to the presenters. Remember, if you would like to speak, we can not un-mute your line UNLESS you have entered your “audio PIN” which was given to you at the start of the call.

Health & Disability Advocates