Perspectives on Essential Health Benefits Workshop Report (2012) / Chapter Skim
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6 Insurer Decisions of Benefit Coverage and Medical Necessity
6 Insurer Decisions of Benefit Coverage and Medical Necessity
Pages 59-70
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From page 59... ...
Dr. Jeffrey Kang then described how CIGNA develops a benefit plan and how the benefits offered by a typical CIGNA employer plan compare to the categories of care listed in Section 1302 in the Patient Protection and Affordable Care Act (ACA)
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From page 60... ...
Therefore, decisions about EHB Reactive Policy Developed to Fix Audit Findings Defer to Community Practice Allow Exceptions Administrative Agility Formalized Consistency External Coverage Benchmarks Advisory Panels Alternative Processes Public Input on Policy for Policy Development Policy Developed Based on Horizon Scanning Proactive FIGURE 6-1 Defining benefit plans requires balancing administrative agility or consistency with the need to proactively or reactively define benefits. SOURCE: Jacques, 2011.
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From page 61... ...
JEFFREY KANG, CIGNA CORPORATION Dr. Kang, the chief medical officer for CIGNA Corporation discussed how CIGNA "constructs" a benefit plan, how covered benefits interact with medical necessity, and which issues the committee might consider as it debates what is "essential" and what defines a "typical" employer.
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From page 62... ...
(1) CIGNA Standard Medical Plan Ambulatory Patient Services Included Included Emergency Services Included Included Hospitalizations Included Included Maternity and Newborn Care Included Included Mental Health and Substance Use Disorder Services, including Included Included behavioral health treatment Prescription Drugs Included Included Rehabilitative Services and Devices Included Included And Habilitative Services and Devices Included Excluded Laboratory Services Included Included Preventive Services Included Included And Wellness Services (Needs Definition)
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From page 63... ...
Dr. Calega, the Vice President for Medical Management and Policy at Highmark Blue Cross Blue Shield (Highmark)
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From page 64... ...
Furthermore, medical management staff keeps abreast of the medical literature to identify new treatments or changes in medical protocols that may neces sitate a change in benefits. Plans also conduct internal performance reviews of their plan portfolios; these reviews consider sales data, medical trends by geographic areas, product types, and benefit designs to ensure meaningful coverage at a variety of price points across different markets.
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From page 65... ...
Calega observed that Congress explicitly preserved the right of group health plans to employ commonly used management techniques like medical necessity.8 BCBSA and Highmark recommend, she said, that the IOM and HHS do not limit the use of medical necessity or other commonly used medical management tools as part of the administration of EHB. The key reasons for the use of these tools by employers and insurers, including the Federal Employees Health Benefits Program (FEHBP)
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From page 66... ...
To evaluate the technology, Aetna has a process in which it looks at evidence in the peer-reviewed literature, the regulatory status, and any relevant clinical practice guidelines and technology assessments. Aetna's clinical coverage criteria are derived from those of the Blue Cross and Blue Shield Association's Technology Evaluation Center (Box 6-1)
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From page 67... ...
Selby noted that Representative James Dunnigan testified that most enrollees in Utah opt for something more rich than the minimum benefit plan and suggested that a "too basic" minimum benefit plan or a tiered benefit structure might be particularly disadvantageous to low-income and sick people (see Chapter 4)
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From page 68... ...
It will be "almost impossible," to include a large number of mandates in the EHB package or require individuals, small businesses, or states that do not currently have these mandates to incur the added cost. Few states have rigorous reviews like the California Health Benefits Review Program (CHBRP)
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From page 69... ...
2010. Interim final rules for group health plans and health insurance issuers relating to internal claims and appeals and external review processes under the Patient Protection and Afford able Care Act; interim final rule.
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