• The largest plan by enrollment in any of the three largest small group insurance products in the state’s small group market;
• Any of the largest three state employee health benefit plans by enrollment;
• Any of the largest three national FEHBP plan options by enrollment; or
• The largest insured commercial non-Medicaid Health Management Organization (HMO) operating in the state.

HHS announced this approach after seeking input from the Institute of Medicine (IOM), the public and the Department of Labor.  HHS intends to propose that if a benchmark is missing categories of benefits, the state must supplement the missing categories using the benefits from any other benchmark option.  Health insurance companies will have some flexibility to adjust benefits.

Since HHS has decided to let states decide EHBs, instead of creating a federal EHBs standard, many fear that states will continue the status quo or even have low EHBs standards because of costs concerns.  The federal government will subsidize coverage based on the essential health benefits, any coverage options above that standard states will have to pick up the cost.

It is important to evaluate how your state ranks regarding insurance coverage and benefits provided for patients with bleeding disorders.  Whether or not there are protections in place, continued advocacy is still necessary.  State advocacy of all stakeholders involved in this process: Legislators, Exchange Boards, Insurance Departments, Executive Branch, etc. will be crucial.

HHS is accepting public comments on the bulletin by Jan 31, 2012. The regulatory process for EHBs will likely continue into the year, guidance on calculating actuarial value, cost sharing and the provision of minimum value by employer-sponsored coverage will be released later, with more opportunities for public comment.

Read HHS press release here.

Read the Bulletin here.

IOM’s report lays out a methodology that should be used to determine ‘essential health benefits’.  The report also emphasized that the benefit package should be affordable based on the average cost of health insurance for small employers in 2014 – when exchanges should be fully implemented. The government should announce their final plan by May 1, 2012 and will hold a series of listening sessions across the country.  Listed below is the IOM report and additional resources.

Institute of Medicine: Essential Health Benefits: Balancing Coverage and Cost

Implementing Health Insurance Exchanges: State Profiles

Kaiser Family Foundation – What is a Health Insurance Exchange?

State Action Towards Creating a Health Insurance Exchange, as of September 23, 2011

Establishing Health Insurance Exchanges: An Update on State Efforts

Implementing Health Insurance Exchanges: State Profiles

Health-care law benefits must be limited to ensure affordability, panel says

Panel Says U.S. Should Weigh Cost in Deciding ‘Essential Health Benefits’

HFA Comment Letter to Institute of Medicine on Essential Health Benefits December 2010

The committee can consider reductions to entitlement programs (such as Medicare, Social Security), tax entitlements, and defense spending.  If recommendations by the special Congressional committee are deadlocked or not approved by Congress by the end of 2011, then more than $1 trillion in automatic spending cuts will be triggered. The cuts could potentially hit defense spending and payments to Medicare providers (not beneficiaries). Below are some resources to help clarify the debt ceiling and the “super committee” created to come up with spending cuts.

If you have a relationship with a member of the Committee or even if your Senator or Representative is on the Committee it would be worthwhile to contact them and express your support for programs that benefit you! including Medicare and Social Security. If you would like assistance in outreach to your member of Congress please don’t hesitate to contact HFA staff.
Super Committee Members

Senate Members
Sen. Patty Murray (D-WA), Co-chair
Sen. John Kerry (D-PA)
Sen. Max Baucus (D-MT)
Sen. Jon Kyl (R-AZ)
Sen. Pat Toomey (R-PA)
Sen. Rob Portman (R-OH)

House Members
Rep. Jeb Hensarling (R-TX), Co-chair
Rep. Dave Camp (R-MI)
Rep. Fred Upton (R-MI)
Rep. Chris Van Hollen (D-MD)
Rep. James Clyburn (D-SC)
Rep. Xavier Becerra (D-CA)
Resources

A section-by-section summary of the Budget Control Act 

New York Times: Q. and A. on the Debt Ceiling

Brookings Institution: Deficit Reduction and the New Congressional Committee: A Primer

Families USA: The Super Committee: Where They Stand on Medicaid, Medicare, and The Affordable Care Act

Coalition for Affordable Health Coverage:  Better Know Your Super Committee

National Womens Law Center: State-by-State Fact Sheets for Super-Committee Advocacy

Debt Budget Deal Time Table

A Who’s Who of the Debt Supercommittee

FAQ: ‘Super Committee’ Could Have Big Impact On Medicare, Medicaid Spending

The Budget Control Act of 2011: Implications for Medicare 

The health care law will disappoint many Americans if its health insurance exchanges don’t deliver decent coverage at affordable rates for consumers, including those with serious illnesses like cancer.

Meeting those expectations may be difficult, judging from comments by a major patient advocacy group as it waits for the Obama administration to release rules governing the development of the exchanges and watches state legislatures draft exchange laws.

For example, the American Cancer Society Cancer Action Network recently released a series of “threshold questions” that states should address if they are going to design exchanges under the laws that meet the needs of cancer patients.

They include: Will boards overseeing exchanges be structured to meet consumer interests? Will insurance market regulations outside of exchanges discourage these marketplaces from becoming a dumping ground for bad insurance risks? Will it be easy for exchange customers to enroll in Medicaid or move from Medicaid to private exchange plans when their incomes rise? Will the exchanges have a stable source of funding? Will they be an “active purchaser” with the power to exclude plans that offer lousy value?

Stephen Finan, senior director of policy for the Cancer Action Network, said in an interview Wednesday that “it’s a mixed bag” in terms of how well states are doing so far on those parameters. Of the dozen or so states with exchange laws, California, Connecticut, and Maryland are “on the good end” of the spectrum and Colorado, Oregon and Nevada are on the “not so good” end, he said.

States that are moving in the right direction have done a good job dealing with critical issues like governance, he said. They are coordinating their outside markets to work well with exchanges and keep them from attracting disproportionate numbers of insurance enrollees who are costly to cover. These states also are on track to coordinate well with Medicaid programs and have a stable source of funding, with plans to charge fees to all insurers in the state, not just those that offer coverage on the exchange.

States performing inadequately, on the other hand, are setting up exchange oversight boards that are too big, or have too many insurers or providers running things. These states won’t coordinate well with the outside market, and they would leave funding of exchanges to the uncertainty of the yearly appropriations process.

The overwhelming majority of states have yet to pass legislation creating exchanges, which means it’s still unknown whether exchanges in most states will prove worthwhile for consumers. Finan said that the upcoming proposed exchange regulation to be issued by HHS could push states in the direction of making good decisions by offering guidance on creating effective exchanges.

But Finan said he thinks the proposal will be very wide ranging. “It could be a soup-to-nuts thing for every option” for creating exchanges, he said. And making a good exchange is a challenging proposition that involves much more then simply knowing about a wide range of design options. “It’s not just the pieces, it’s how they fit together,” he said. “It’s not an easy thing to build a good exchange.”

“What we hope is that the final regulation will establish clear minimum standards,” he said. “I don’t think we’ll see that in the proposal,” he added, predicting that it will list a wide array of design options in order to draw a wide range of comments.

Consumer advocates may face difficulty obtaining a final exchange regulation to their liking.

Republicans have traditionally been strong allies of the insurance industry, and the industry has a history of turning exchanges into dumping grounds for bad risks. But Finan says that consumer groups are coordinating their efforts to produce exchanges that work well for their members.

“The insurance groups have been talking regularly for almost a year,” he said. “We have weekly phone calls on exchange-related issues. We’re trying first and foremost to exchange information and educate each other.” In addition to the American Cancer Society, groups involved in the talks include Consumers Union, the Center on Budget and Policy Priorities, AARP, Families USA, the Small Business Majority, Health Care for American Now, SEIU, and the National Partnership for Women and Families. Finan said that in the end they may submit a common letter commenting on the proposed rule. If not, “I think there will be a fairly uniform set of messages,” he said.

John Reichard can be reached at jreichard@cq.com

New England Journal of Medicine

Auditing Access to Specialty Care for Children with Public Insurance

Health and Human Services officials have encouraged states over the past year or so to act sooner rather than later to pass legislation governing the creation of health insurance exchanges — without going out of their way to suggest that there’s another approach.

But officials confirmed to CQ HealthBeat on Tuesday that in fact there is another way a state can have an exchange, adding that it’s not a matter of new policy for them to say so. The other approach in question is a state governor issuing an executive order creating an exchange. That tactic is being explored by a number of states as a way to get exchanges going after lawmakers have balked at passing exchange laws in the face of tea party protests, Politico reported Tuesday.

HHS officials said that in their “initial guidance” document released to states, the agency states that: “Establishment of an exchange requires a planning process leading to State action, by legislation or other means, to create an exchange entity with the authority necessary to meet all the exchange requirements of the Affordable Care Act.”

The key words in that statement are “or by other means.” Officials said that language also appeared in information to the states on applying for grants to establish exchanges.

Officials said Tuesday that if state law permits issuance of an executive order to create an exchange and the order meets requirements in the health care law for creation of exchange, then in general, doing so would be permissible.