Implementation of the ACA: Essential Health Benefits

Transcription

1 Implementation of the ACA: Essential Health Benefits 2013 Disability Policy Seminar April 15, 2012 Theresa T. Morgan Powers Pyles Sutter & Verville, P.C

2 Outline! Essential Health Benefits: Legislative History! EHB: Regulatory Timeline! State s Role in Defining EHB! Habilitation! EHB and State Mandates! Non-Discrimination Provisions! Comparing Plans! Next Steps: State legislation, education and monitoring 2

3 Essential Health Benefits: Legislative History! In March 2010, Congress passes ACA, which includes guarantee issue and individual coverage requirements, to kick in next year! ACA sets a minimum benefits coverage standard in order to assess whether these requirements are met! Specifically, ACA says that starting in 2014, most new small group and individual plans, as well as Medicaid benchmark and benchmark equivalent plans, must cover essential health benefits (EHB)! EHB is not defined by the ACA, except for listing ten broad categories of benefits and requiring coverage must be equal in scope to typical employer plan! Congress instructs HHS to further define EHB 3

4 Essential Health Benefits: Regulatory Timeline! HHS issues guidance in December of 2011 proposing a state-bystate benchmark approach to defining the 10 categories of EHB! HHS receives over 10,000 comments to this guidance! HHS conducts listening sessions to hear from stakeholders on their approach! HHS issues data collection proposed rule in early summer 2012! After the Supreme Court decision, HHS issues final data collection regulation! After 2012 Presidential election, HHS issues proposed EHB regulation! At the same time, HHS also issues proposed rule on the mulitstate plan program, which will allow issuers to offer the same plan in up to 50 states! HHS allowed for 30 days to comment on both of the regulations! HHS has issued the final rules for both EHB And MSPP, and the proposed rule for Medicaid ABPs 4

5 States Role in Defining EHB! States have selected (or defaulted to) a benchmark plan from the following choices: (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 plan options by enrollment; or (4) The largest insured commercial non-medicaid HMO operating in the State.! Once a benchmark was selected. States or HHS reviewed plan data to determine if a benefit category was missing in its entirety! If a benefit category was missing, the plan was supplemented with a benchmark for that category, if in existence! States will continue to have oversight and enforcement authority of issuers, even working in the new marketplaces! Exchanges will certify the plans meet ACA requirements, including EHB 5

6 States Role in Defining Habilitation as an EHB! HHS does not define habilitation in EHB regulation! HHS presumes habilitation benchmark not available to states for adopting into their EHB plan! HHS allows for 1) states to define habilitation or 2) plans to cover habilitation at parity with rehabilitation or provide a different standard and report to HHS in 2016 what that standard is! For MSPP, OPM will define habilitation, but final rule does not say what standard they will use! Proposed Medicaid benefit regulation proposes to have states define habilitation for Medicaid benchmark plans or require plans to cover habilitation at parity with rehabilitation, in terms of amount, duration and scope 6

7 EHB and State Mandates! The question of whether state mandates are included in EHB is a critical one: 1) Only EHB (as opposed to benefits deemed non-essential) must be covered under the federal requirement, though states can require plans to cover non-ehb 2) States must cover the difference in cost for adding non-ehb to the minimum benefits requirement! In the final regulation, HHS assumes all state mandates before January 1, 2012, are EHB 7

8 EHB and Non-Discrimination! The statute requires, and the final EHB regulation references in part, that in defining essential health benefits the Secretary (and plans) must: Ensure that such essential health benefits reflect an appropriate balance among the categories so that benefits are not unduly weighted toward any category Not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of disability Take into account the health care needs of diverse segments of the population, including persons with disabilities Ensure that health benefits established as essential not be subject to denial to individuals against their wishes on the basis of the individual s present or predicted disability, degree of medical dependency or quality of life Periodically review the essential benefits and determine need to update based on changes in medical evidence or scientific advancement (HHS plans to review the benchmark process in 2016) 8

9 Comparing Benefit Plans: Summary of Benefits Coverage and Glossary of Terms! HHS releases final regulations on summary of benefits coverage and glossary of terms! Development and utilization of uniform explanation of coverage documents and standardized definitions, which are non-binding:! Terms such as rehabilitation and habilitation services, durable medical equipment and medical necessity! definition of habilitation reads: Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. (See, NAIC Glossary of Terms for the Affordable Care Act.) [Emphasis added.] 9

10 Next Steps: Education, Legislation and Monitoring! Educate consumers, providers and policymakers about the essential nature of your services! Advocate for coverage without arbitrary limits or exclusions that discriminate against people with disabilities! Report to your state and federal partners the experience in your state 10