Perspectives on Essential Health Benefits Workshop Report (2012) / Chapter Skim
Currently Skimming:
4 State Experiences with Defining a Minimum Benefit Standard
4 State Experiences with Defining a Minimum Benefit Standard
Pages 37-50
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 37... ...
AND THE NATIONAL BUREAU OF ECONOMIC RESEARCH (NBER) As a founding member of the Massachusetts Health Insurance Connector Authority Board, and as an advisor to Congress and the Obama administration during the development of the Patient Protection and Affordable Care Act (ACA)
|
From page 38... ...
" Limitations on Coverage Although the ACA prohibits annual and lifetime limits on coverage, it does not "rule out more specific limits," such as limits on the number of mental health or physical therapy visits, or step therapies (e.g., requiring certain prescription drug regimens such as starting treatment with a generic drug)
|
From page 39... ...
Of course, he said, if the package "gets more generous," costs will rise with a variety of possible impacts. For instance, the individual mandate clause stipulates that if individuals would have to pay more than 8 percent of their income for health insurance, they are not subject to the mandate.3 A more generous, and thus more expensive EHB package, would therefore lead to more individuals eligible for exclusion from the mandate.
|
From page 40... ...
Gruber explained the "minimum creditable coverage" mandated by the Massachusetts legislature. He defined minimum creditable coverage as "the minimum level of coverage that people could hold and still meet the individual mandate." He provided four examples to illustrate some of the issues the Commonwealth Health Insurance Connector Authority Board faced when developing the minimum creditable coverage requirements: removing lifetime limits, removing annual limits in the young adult plan, mandating prescription drug coverage, and providing maternity coverage for dependents.
|
From page 41... ...
Kingsdale identified a further challenge in defining the EHB: the ACA does not have broad stakeholder support, and the committee "is undertaking its task in a highly divided nation." In Massachusetts, state reform efforts enjoyed "broad political support." Whatever is put into the EHB package, he said, "can be portrayed by opponents of the ACA as unfairly burdening employers 6Commonwealth Health Insurance Connector Authority 956 CMR 5.00: Minimum Creditable Coverage. Full text available at http://www.
|
From page 42... ...
There is a tendency, he said, to think about benefits in the context of "something someone else will pay for." He noted, however, that "there are real people who cannot afford what we consider to be an ideal benefit package, and they actually have to pay for it in premiums." Dr. Kingsdale said his experience implementing components of Massachusetts' health reform law, 7 including defining minimum creditable coverage, suggests that there is broader popular and political support of the goal of reform laws, such as the ACA, being "about giving more people decent coverage as opposed to being about raising the standard of coverage." He advised the committee, therefore, that when it has to "make decisions about close calls regarding benefits," it is important to return to this purpose as a guiding principle.
|
From page 43... ...
Throughout the entire process, the task force grappled with the question of "what are essential benefits," as well as what benefits were important to the public and what the role of cost in determining the benefit plan would be. Ultimately, the task force recommended specific covered services, limitations, and exclusions, and the cost sharing for indemnity, PPO, health maintenance organization (HMO)
|
From page 44... ...
For example, the ACA prohibits lifetime limits and phases out annual limits. Additionally, for employers with more than 50 employees, the Paul Wellstone and Pete Domenici Mental Health 8The Maryland Insurance Administration also surveyed the largest carriers in 2008 regarding the top five benefit plans sold to small employers.
|
From page 45... ...
Parity and Addiction Equity Act of 20089 prohibits service4-1 and cost sharing for mental health and substance Figure limits abuse treatments that are more restrictive than the service limits and cost sharing for most medical-surgical benefits.
|
From page 46... ...
State exchanges, he suggested, "can be laboratories for exploring different limits and the kind of cost-sharing designs that make sense." PRESENTATION BY REPRESENTATIVE JAMES DUNNIGAN, STATE OF UTAH HOUSE OF REPRESENTATIVES Representative Dunnigan, an insurance broker with Dunnigan Insurance, has served in the Utah House of Representatives since 2003, and as Chairman of the Utah Health Exchange Oversight and Implementation Work ing Group has been involved in the debate and the development of Utah's health reform law, passed in 2008. 10 He began by noting that he was speaking on behalf of state legislatures across the nation in urging the committee to recognize state differences and the impact of EHB decisions on state budgets.
|
From page 47... ...
Nelson to ask for further details about how the state determined the basic benefit package. Representative Dunnigan said the basic benefit package has been in place for "a number of years." Utah NetCare, which is Utah's "version of an EHB package," was designed to be a third less expensive than the average employer-based premium in the market.
|
From page 48... ...
State Flexibility Mr. Salo echoed Representative Dunnigan in saying that because political and cultural factors drive health insurance regulation, benefit mandate decisions, and benefit design, state-by-state decision making is necessary.
|
From page 49... ...
The Maryland CSHBP experience. PowerPoint presentation to the IOM Committee on the Determination of Essential Health Benefits by Rex Cowdry, Executive Director, Maryland Health Care Commission, Washington, DC, January 13.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.