There are four advisory committees to the Exchange Board and I am on two of them. Next Monday, the Health Plan committee will make a recommendation about the essential health benefits package -- the floor for what all insurance plans written in Connecticut will have to cover. The information we were given by the Exchange staff is totally insufficient. They've told us that if we choose a plan that covers the "mandates" -- coverage that is required by state law, like the first $1000 of ostomy supplies, wigs for cancer patients, overnight stays for mastectomies -- we may end up (maybe, if the feds make a change in 2016) having to pay for those to the extent that people are getting subsidies to buy policies that include them. That's a straw man -- yet another excuse to try to rob consumers of the benefits of these mandates, for which we fought for years and years to achieve.
There are a zillion questions implicated by the choice of the EHB. I sent an email to the Board, advisory committee members, and Exchange staff asking several of those questions:
I have some questions and concerns that I thought it might be useful to share in advance of our scheduled meetings to discuss the EHB. While the so-called “mandates” certainly are one factor, there are many other issues to consider. I wonder if staff could help to pull together some additional information that I think would be instructive. For example:
1. Which of Connecticut’s “mandates” fall within the 10 areas that the ACA requires to be included in the EHB? For example, mental health parity is mandated by federal law, so as a Connecticut “mandate,” this adds nothing to the cost for Connecticut insureds. Similarly, coverage of children to age 26 under their parents’ policy is mandated by the ACA and, thus, there would be no cost to Connecticut of having an EHB that matches this requirement. This is true for many of the Connecticut coverage requirements.
2. In Appendix II, you have indicated where the possible benchmark plans match or do not match the 10 ACA requirements. However, what you have not told us for each service is whether there are limits on those benefits. For example, in Appendix II, you state that rehabilitative services are covered, but you do not state the limitations on rehabilitative services, some of which are indicated in Appendix III, but in comparing benchmarks, it is very important to consider not just whether a service is covered, but also the extent to which it is covered. Is there a limit on outpatient mental health visits, for example? Visit limits are something we should look at; it’s unclear whether states can choose a benchmark but without visit limits.
3. In Appendix III, you include a Cigna plan and an Aetna plan. However, these are not listed as among the potential benchmarks. Why are they included here?
4. How did you decide what services are included in each of the ten ACA-EHB categories? For example, I would have included physical, speech, and occupational therapy under Rehabilitative and Habilitative. It does not appear that you looked at these services. The ACA creates 10 “buckets,” but what falls within each “bucket” is something that we have to try to determine. I’m attaching a powerpoint presentation given by the Center on Budget and Policy Priorities and the Kaiser Family Foundation that illustrates this very well.
5. While I know that it is critical that the EHB address the 10 ACA categories, shouldn’t we also be comparing the benchmark options regarding other categories of services? For example, which plans cover imaging (ConnectiCare limits it, Oxford includes it, Anthem includes it, according to data on the plans found in Healthcare.gov)? Similarly, Anthem and ConnectiCare cover home health care, but Oxford limits it. To the extent that the benchmarks are very similar for purposes of the 10 ACA categories, don’t we need to look beyond those 10 categories to see which plan provides the best benefit package?
6. With respect to prescription drugs, while the plans all cover drugs, the ACA and HHS guidance say that the plan must include at least 1 drug in each class (whereas Medicare Part D requires 2 drugs per class, and some categories are protected, like HIV, psychotropic meds). Shouldn’t we know what each benchmark plan’s prescription drug benefit covers? And shouldn’t we consider whether a plan excludes brand name drugs or uses specialty tiers for expensive drugs?
7. What services are expressly excluded by each benchmark plan?
8. What services require prior authorization and would that prior authorization requirement be carried over to an EHB modeled on one of the benchmark plans?
Of course, these are not the only considerations we should be looking at, but I feel strongly that we need at least this much additional information on all of the plans we are considering as benchmarks. It would be helpful if staff could compile this sort of information before the advisory committees meet to discuss this most critical issue.
My response? I got a phone call from the Exchange staff saying that I shouldn't worry, all of these questions will be answered in good time. For now, their communication to us is just "informational." But the EHB is on the agenda for Monday. Every month's agenda is already set. There is no time to make a recommendation about the EHB at a later date. I am nothing short of frantic about the possibility that such an important decision will be made by people who don't understand the basics, who haven't read the federal regulations, who aren't well informed.
I don't know what to do to stop this, either. What I can say is that if you are from Connecticut and you are reading this, PLEASE contact the Governor's office (800) 406-1527, the Lieutenant Governor's Office (she's also the Chair of the Exchange Board) (866) 712-6998, and your state legislators and tell them that their failure to add consumers to the Exchange Board means that the Exchange is not in compliance with federal law. To find your state legislators, go here.
It's sort of amusing (in a sick sort of way) that the argument AGAINST appointing consumers to the Exchange is that they don't understand the system well enough to make a genuine contribution, while it is clear that the Exchange Board members know far less about this than I do. But let me tell you -- there are a bunch of uninformed people who are about to make a decision that will govern the benefit structure of EVERY insurance policy sold in the State of Connecticut. That they propose to do that without consumer input, and without even understanding the implications of what they are doing, is a complete outrage. Please, please, speak up NOW. Jennifer