Illinois Begins Essential Health Benefits Discussion

Governor Pat Quinn recently announced that the benchmark plan for Illinois’ Essential Health Benefits (EHB) package will be chosen by September 30, in order to meet the Federal deadline for selecting a plan. A public meeting on Wednesday, September 12th, will provide the public and other stakeholders an opportunity to weigh in on this crucial piece of the health care law’s implementation in Illinois.

The EHB package defines the baseline of services covered by health insurance plans offered to individuals and small businesses in the state.

Last December, The Department of Health and Human Services released a bulletin with guidelines for states to select their own EHB plans. The guidelines feature 10 different categories of benefits that each plan must cover, such as “emergency services,” “rehabilitative and habilitative services,” “prescription drugs,” and “mental health and substance abuse services.”

States must select a health insurance plan that is currently operating within the state to act as the EHB benchmark, with the largest small group market plan in the state acting as the default benchmark if the state fails to meet the September 30 deadline. If the selected plan does not provide adequate coverage of one of the ten benefits categories, that category will be supplemented with a coverage package from a different potential plan.

Once selected, the EHB will define the level of care that individual and small group insurance plans must offer in Illinois. Benchmark plans can specify the scope or duration of benefits, but they cannot place dollar limits on copays or deductibles, as well as lifetime annual dollar limits on coverage. Plans offered to consumers in health insurance exchanges will be required to meet the level of coverage ensured by the EHB package. However, insurance companies will have the opportunity to make substitutions within the ten categories of benefits, as long as those substitutions are not found to reduce the value of coverage offered.

The Illinois Health Care Reform Implementation Council will be hosting a meeting on Wednesday, September 12, 2012, where the public and other stakeholders will be able to make comments on the state’s EHB selection. The committee will continue to accept comments until September 19. Comments can be submitted through the Governor’s health reform website.

Check back soon for an update on the EHB selection process following Wednesday’s meeting!

The Essential Health Benefits--Comments from Health and Disability Advocates

On December 16^th 2011, the Department of Health and Human Services released a much-anticipated bulletin on the Essential Health Benefits (EHB) package. Instead of containing information on what the package would contain, the bulletin deferred the task of defining EHB to each state. Supplementary information designed to clarify the approach taken in the bulletin was released on January 25, 2012.

Health & Disability Advocates, the organization which powers Illinois Health Matters, submitted their comments on these bulletins to HHS on January 31, 2012, reflecting specific concerns:

The role of the EHB package was to create a standard of health care covered by insurers for all Americans purchasing insurance through the state exchanges. This would mean a standard of adequate care for all, without discrimination due to age, gender, disability, chronic illness or geographical location.  It is the vehicle that would bring the goal of health care reform, that is, high-quality, comprehensive care, to many citizens.

The proposed plan gives states a vague benchmark system, with no federal oversight currently put in place, to use in defining the EHB. Although it is understandable for states to want flexibility in defining their EHB package, the degree of flexibility HHs is allowing could permit states the freedom to eliminate important benefits or the protection the EHB provides against insurance discrimination. Furthermore, to hand off all of the important decisions regarding the EHB package to the states goes against Congress’s intentions in the ACA of a federal standard, defined by HHS, for minimum coverage. As HDA states in their comments, “Simply said, the HHS EHB Bulletin is inadequate at best, and at worst, is an impediment to effective implementation” of health care reform.

HDA urges HHS to protect the potential of EHB plans by establishing an official, federal oversight process that involves a diverse range of perspectives, including those of people with disabilities and chronic illness. The HDA comments outline specific suggestions for the development of an EHB plan going forward that would safeguard the potential benefit of the EHB package, including the following:

•  Reflects an appropriate balance among the categories describes in such subsection, so that benefits are not unduly weighted toward any category
• Does not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life.
• Takes into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups
• Ensures that health benefits established as essential are not subject to denial to individuals on the basis of the individuals’ age or expected length of life or of the individuals’ present or predicted disability, degree or medical dependency, or quality of life.

To read the full list of HDA’s specific concerns, read the full comments here.

Barbara A. Otto

Chief Executive Officer

Health & Disability Advocates

Essential Health Benefits: What’s it mean for people with HIV?

On December 16, 2011, the U.S. Department of Health and Human Services (HHS) announced that states would decide what essential health benefits will be provided under health care reform.  Although we had urged HHS to adopt a uniform, national benefits floor that states could build on, the federal proposal offers important flexibility for states. (Check out our essential health benefits archive.)

So, what does the essential health benefits announcement mean for people with HIV?  The short answer is that we’re working on it.  Here are some of the hoops we’ll have to jump through just to figure out what the benefits might look like in a state.

Which plans are we talking about?  HHS gives states the choice of:

(1) the largest plan by enrollment in any of the three largest small group insurance products in the State’s small group market;
(2) any of the largest three State employee health benefit plans by enrollment;
(3) any of the largest three national FEHBP [Federal Employee Health Benefit Plan] plan options by enrollment; or
(4) the largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the State.

Yeah, we weren’t sure where to start either.  There’s no centralized federal repository of health plan data, since states regulate health insurance.  Every state publishes plan information online differently, or not at all.  We’ll probably have to submit a special data request to each of the 50 state insurance departments.

What benefits does each plan offer?  Once advocates identify the largest plans, the next step is to determine exactly what benefits they offer.  You can bet that Blue Cross doesn’t publish on their website a description of each of their hundreds of plans offered in a state.  We’ll might have to ask companies directly for plan descriptions, or pour through regulatory filings at state insurance departments.

Once we have this information, we can start to figure out what the plans will look like for people with HIV.  Of course, we’ll partner with national and state advocates to gather and analyze information.  At the state level, it’s more essential than ever that advocates work together to figure out the benefit puzzle and don’t duplicate effort.

And here’s an idea:  Could advocates, employers and insurance companies collaborate to gather all this information?  Sure, old adversaries would have to sit at the same conference table to share opinions and information – but that might be just “what the doctor ordered” in the new world of health care.

Read the federal fact sheet
Read the HHS Essential Health Benefits Bulletin
Federal white paper on benefits in small group and state and federal plans
Federal fact sheet on individual market benefits

John Peller, VP of Policy
AIDS Foundation of Chicago
jpeller@aidschicago.org

Originally posted here on HIVHealthReform.org