Perspectives on Essential Health Benefits Workshop Report (2012) / Chapter Skim
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12 Lessons from California's Benefit Review Processes
12 Lessons from California's Benefit Review Processes
Pages 129-140
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From page 129... ...
Ehnes; Maureen McKennan, the Acting Deputy Director for Plan and Provider Relations; and Andrew George, the Assistant Deputy Director of the Help Center -- were asked to compare and contrast the Knox-Keene Act's covered benefits with the ACA's EHB and to describe the DMHC's legislatively mandated appeals and external review processes. Because there is a question of the extent to which state mandates should be included in the EHB, Susan Philip, Director of the California Health Benefits Review Program (CHBRP)
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From page 130... ...
• When the plan denies a grievance, the plan needs to inform the enrollee of the right to appeal to the DMHC. Unless an earlier review by the DMHC is warranted, enrollees must first exhaust the plan's internal grievance and appeals processes before appealing to the DMHC, but enrollees are not limited in the content and issues about which they can appeal, including access to care and denial of service.
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From page 131... ...
When disputes involve both a coverage determination and a health care service question, such as disputes related to reconstructive surgery, oral surgery, and some services for autism, the DMHC is the "final arbiter" on whether the grievance should proceed through the standard complaint process or an IMR. Independent Medical Review An IMR is a process by which expert independent medical professionals assess clinical coverage decisions made by an insurance company.
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From page 132... ...
visits. Medical Necessity Medical necessity IMRs occur when a provider recommends a health care service and the plan denies the service throughout the plan's internal appeals process on the grounds that it is medical unnecessary.
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From page 133... ...
In these cases, the IMR reviewer applies a "prudent layperson" standard to determine whether the enrollee "acted reasonably in seeking emergency services." Grievances and Appeals Under the ACA ACA requires plans to have internal and external grievance and appeals processes. 5 Until further regulatory guidance is provided, the HHS has deemed most states' external review processes as compliant with the interim regulations.
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From page 134... ...
Established in 2002 by the state legislature, CHBRP's researchers (i.e., faculty and researchers from the University of California, San Francisco, and the University of California, San Diego, and program staff) analyze the medical effectiveness, cost, and public health impact of pro posed state legislative health insurance benefit mandates or repeals and provide this independent, evidence-based information to the legislature.
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From page 135... ...
, which prompted Ms. Philip to reiterate that CHBRP studies the marginal cost of the mandates whereas other studies, she said, "actually look at the cost of the benefit as a whole as opposed to looking at the marginal impact of the requirement." 7 In other words, removing all mandates would not mean that plans would drop all coverage since there is considerable overlap with basic health care services and since the market may continue to demand the benefit or service.
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From page 136... ...
If there is not enough evidence to actually draw a conclusion, she said, then it is important to highlight the lack of a strong evidence base. In CHBRP's experience, when a mandated benefit 8 California Assembly Committee on Health Bill 161: Health care coverage: Chemotherapy treatment.
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From page 137... ...
Wright said, consumers and small businesses were asked for their opinions about what constitutes basic health benefits. The list, he said, was "remarkably consistent" from group to group and included physician services, hospitalization and ambulatory care, diagnostic laboratory tests, diagnostic and therapeutic radiology, home health services, preventive health services, emergency health care services, hospice care, prescription drug coverage, and mental health parity.
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From page 138... ...
Consumer Insights on Benefit Mandates and Exclusions Mr. Wright stated that Health Access supports some state benefit mandates, including mental health parity and coverage of prenatal and maternity care in the individual market.
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From page 139... ...
Furthermore, Mr. Wright advised the committee that "consideration of affordability must include not just premiums, but the full costs to the patient, including cost sharing due to co-payments, deductibles, and benefits not covered." He reiterated that "you want to give people confidence in their coverage." REFERENCES CHBRP (California Health Benefits Review Program)
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