Background - Families USA The Voice for Health Care Consumers背景：美國家庭醫(yī)療保健消費(fèi)者的聲音課件

JinaDhillonJD,MPH“SecuringHealthRightsforThoseinNeed”EssentialHealthBenefitsJinaDhillon“SecuringHealthR1

RoadmapBackgroundOverviewofHHSBulletinKeyconcernsandadvocacyresponseRoadmapBackground2BackgroundSecretarymustdefineessentialhealthbenefits(EHB)packageEHBmustbeequivalenttotypicalemployercoverageEHBmustcovertencategoriesofservicesACA§1302Background3BackgroundTenCategoriesAmbulatorypatientservicesEmergencyservicesHospitalizationMaternityandnewborncareMentalhealth,substanceabuse,behavioralhealthPrescriptiondrugsRehabilitative&habilitativeservices&devicesLaboratoryServicesPreventiveandwellnessservices,chronicdiseasemanagementPediatric,includingoral&visioncareACA§1302(b)(1)BackgroundTenCategoriesAmbula4

HHSBulletinIntendedRegulatoryApproachEHBwillbedefinedbyreferencetoabenchmarkplanselectedbyeachStatefromfollowingfourgeneralcategories(2014and2015):Largestplaninanyofthreelargestsmallgroupinsuranceproducts*;AnyoflargestStateemployeehealthbenefitplans;AnyoflargestthreenationalFEHBPplanoptions;ORLargestinsuredcommercialnon-MedicaidHMO*IfStatedoesnotselectabenchmark,thisisthedefault.HHSBulletinIntendedRegulato5HHSBulletinBenchmarkApproachand10CategoriesBenchmarkapproachintendedtosatisfy§1302(b)(2)(A)requiringEHBtoreflectscopeof“typicalemployerplan”Tosatisfyrequirementtocoverall10categoriesin§1302(b)(1),Statemayneedtosupplementbenchmarkplanifthebenchmarkoffersnocoverageinacategoryofbenefits**Mostcommonlynon-coveredcategories,asidentifiedbyHHS,arehabilitativeservicesandpediatricoralandvisionservices.HHSBulletinBenchmarkApproach6HHSBulletinStatescovercostsofbenefitsbeyondEHBACArequiresthatStatemustpayformandatedbenefitsinexcessofEHBFor2014and2015,ifStateselectsbenchmarksubjecttomandates,thosemandatesarepartoftheState’sEHBpackageandStatewouldnothavetodefraythosecosts.HHSBulletinStatescovercosts7HHSBulletinBenefitDesignFlexibilityHealthplansgivenflexibilitytoofferbenefitsthatare“substantiallyequal”tobenefitsofthebenchmarkplanselectedbyState,asmodifiedtomeet10categoriesHealthplanscanadjustbenefits(bothspecificservicesand/orquantitativelimits)solongastheycontinuetocoverall10statutorycategoriesHHSBulletinBenefitDesignFle8HHSBulletinUpdatingEHBsACA§1302(b)(4)(G)and(H)requiresregularreviewandupdatingofEHBbySecretarySeekingcommentonhowtoassessenrolleedifficultieswithaccessduetocoverageorcost,changesinmedicalevidence,ormarketchanges.HHSassumesthe“substantiallyequal”standardforhealthplansandtheirannualupdateofbenefitswillreflectimprovementsinthequalityandpracticeofmedicine.PlanningtoproposeaprocessforevaluatingbenchmarkprocessHHSBulletinUpdatingEHBs9KeyConcernsLackofaFederalMinimumStandardACAdirectsSecretarytodefine,review,andupdateEHBpackageStateandinsurerflexibilitywillresultinvaryingpackagesacrosscountryStatesshouldhaveflexibilitytogoaboveafederalfloor,butnotbelowNoinsurerflexibilityunderanycircumstancesACAintentistoensurecomprehensiveandseamlesscoverageKeyConcernsLackofaFederal10KeyConcernsMinimizingHarmofBenchmarkFrameworkBenchmarksshouldbesubjecttominimumnationalfloorofcoverageLooktoMedicaidprogramforbetterbenchmarkoptionsAlsopromotesseamlesscoverageforfolkstransitioningbetweenMedicaidandExchangeEliminatesmallgroupproductoptionincurrentbenchmarkschemeNobenefitsubstitutionKeyConcernsMinimizingHarmof11KeyConcernsEHBshouldbe:TypicalEmployerPlanPLUSTenStatutoryCategoriesTencategoriesintentionallyaddressgapsinexistingcoverageCongressionalintenttotransformhealthcoverageanddeliverysystemsInvestmentinpromotinghealthoverlongterm,notjustshort-termsavingsKeyConcernsEHBshouldbe:Typ12KeyConcernsStateMandatesStatesmaychoosebenchmarksthatdon’tincludeimportantmandatedservicesBecausestatespayforservicestheyrequirebeyondtheEHB,incentiveforStatestophaseoutmandatesStronglyencourageprocessforreviewingandincludingevidence-basedorotherwisevaluablemandatedbenefitsKeyConcernsStateMandates13KeyConcernsHarmfulUtilizationManagementPracticesHealthplansmayuserestrictiveordiscriminatoryservicelimits,medicalnecessitydefinitions,andotherutilizationmanagementpoliciestodisruptconsumeraccesstonecessarycareNeedstrongstandardsformedicalnecessityandotherprotectionsPlansmustensurelinguisticallyandculturallyappropriateservicesanddeliveryKeyConcernsHarmfulUtilizatio14KeyConcernsNon-discriminationACA§1557andEHBprovision(§1302)prohibitdiscriminationExcessiveflexibilitycausingdiscriminatoryadverseselectionmustbeeliminatedRegularReviewandUpdatingofEHBPackageMustensuretransparentprocesswithpublicinputtoevaluateandu