Perspectives on Essential Health Benefits Workshop Report (2012) / Chapter Skim
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11 Deciding What Is Essential and Evidence-Based in Two States for Public Insurance Programs
11 Deciding What Is Essential and Evidence-Based in Two States for Public Insurance Programs
Pages 117-128
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From page 117... ...
Jeffery Thompson is the Chief Medical Officer of Washington State's Depart ment of Social and Health Services and the Health Care Authority, which operates the state's Medicaid program, an expansion program for low income individuals not eligible for Medicaid called Basic Health Plan, and the state employee benefits program. He discussed how state-covered plans employ evidence to make coverage decisions.
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From page 118... ...
4 These expansions might take the form of Medicaid benchmark,5 benchmark-equivalent,5 or state basic health insurance designs;6 these expansions, plus the plans offered in the exchanges, must all include the EHB. Under the Deficit Reduction Act of 2005,7 benchmark plans were first authorized for state Medicaid programs as a method of cost containment by allowing slimmer benefits than traditional Medicaid.
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From page 119... ...
State Basic Health Plans State basic health plans are an option for individuals between 133 and 200 percent of the federal poverty level (FPL) 8 (replacing the exchange subsidy for that population9)
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From page 120... ...
Ms. Ingram said, for example, that most states do not currently offer habilitation services to their traditional adult Medicaid population; if these services are mandated as an essential benefit for Medicaid programs, states will have higher Medicaid costs.
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From page 121... ...
PRESENTATION BY DR. JEFFERY THOMPSON, WASHINGTON STATE DEPARTMENT OF SOCIAL AND HEALTH SERVICES The Washington State Department of Social and Health Services operates the state's Medicaid program, state employee benefits program, and basic health plan.
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From page 122... ...
(WAC 388-501-0165) A A = Randomized controlled clinical trials B = Consistent and well done observational B studies DSHS generally approves above the line WA Draws a Line Below the line, provider needs to show the evidence or DSHS will disapprove via Prior Authorization C C = Inconsistent studies D = Studies show no evidence, raise safety D issues, or no support by expert opinion 1 FIGURE 11-2 The Washington Department of Social and Health Services uses levels of evidence to choose covered benefits.
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From page 123... ...
According to Dr. Thompson, the state prevails 98 to 99 percent of the time for cases that are unrelated to durable medical equipment, principally because administrative law judges understand the evidence-based benefit system.
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From page 124... ...
State Basic Health beneficiaries under the Medicaid expansion, for instance, are covered for 12 visits (i.e., up to a combined maximum of 12 therapy visits per year with no more than six being for chiropractic care; visits qualify only when used as post-operative treatment following reconstructive joint surgery and must be within one year of surgery)
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From page 125... ...
Hole-Curry noted that while committee members are appointed by the head of the Washington Health Care Authority, the com mittee is shielded from legislative and political influence. If a legislator wishes to provide comments to the commit tee, for example, the legislator speaks to a member of the HTA program staff who then provides these comments to the committee during the public comment period.
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From page 126... ...
Hole-Curry encounters "resistance to public examination" of benefits. She posed an alternate way of thinking about the "real fear" people have that evidence is going to be used "as a way WA HTA Comparison with Insurer Policies Reference Sources BCBS WA HTA Private Insurer Medicare TEC Topic Date Coverage Aetna Group Premera- Regence NCD Health BS -BC Decision Not covered Upright MRI May-07 Less No Same Same No No restrictive decision decision decision Not covered Ped Bariatric Aug-07 Less Less Same Same n/a No Surgery <18 restrictive restrictive decision Conditional Ped Bariatric Same Same Less Less Less Same restrictive restrictive restrictive Surgery 18-21 Conditional Lumbar Fusion for Nov-07 More No Same Same No No DDD restrictive decision decision decision Not covered Discography for Feb-08 Less Same No No No No DDD restrictive decision decision decision decision Not covered Virtual Colonoscopy Feb-08 Same Same Same Same Same Less (CTC)
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From page 127... ...
PowerPoint Presentation to the IOM Committee on the Determination of Essential Health Benefits by Jeffery Thompson, Chief Medical Officer, Washington Medicaid Program, Washington State Department of Social and Health Services, Costa Mesa, CA, March 2.
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