Bare ne­ces­si­ties

Lit­tle state progress on defin­ing cov­er­age re­quire­ments

Modern Healthcare - - THE WEEK IN HEALTHCARE - Me­lanie Evans

Ar­chi­tects of the Pa­tient Pro­tec­tion and Af­ford­able Care Act made a deal, of sorts, with the na­tion’s unin­sured. The law man­dated that nearly ev­ery­one carry in­sur­ance, whether pro­vided by an em­ployer or bought in the mar­ket­place. But it also sought to guar­an­tee the ben­e­fits would be ad­e­quate and af­ford­able.

Now states are busy de­cid­ing how well that deal holds up for the sick­est pa­tients.

The health re­form law man­dates 10 broad cat­e­gories of care that must be cov­ered but says noth­ing about what that cov­er­age will look like or what re­stric­tions or lim­its will ap­ply to the ben­e­fits. Those de­ci­sions, fed­eral health of­fi­cials said in De­cem­ber, will be made by the states, which in­di­vid­u­ally must se­lect a health plan be­fore Sept. 30 that will be the bench­mark for ben­e­fits sold in the mar­ket.

The law re­quires that in­sur­ers in­clude am­bu­la­tory, emer­gency and hospi­tal care, as well as pre­scrip­tion drug cov­er­age and lab­o­ra­tory ser­vices. Care for ex­pec­tant moth­ers and new­borns, of­ten omit­ted from health plans sold to in­di­vid­u­als, must be cov­ered, along with pe­di­atric ser­vices. Preven­tion, well­ness and chron­icdis­ease man­age­ment—one fo­cus of the law’s pay­ment re­form ef­forts—must also be cov­ered. Men­tal-health and sub­stance­abuse treat­ment ser­vices and re­ha­bil­i­ta­tive and ha­bil­i­ta­tive care are re­quired, as well.

Health pol­icy ex­perts say cov­er­age ex­pan­sion un­der the law will pro­vide sig­nif­i­cant ac­cess and fi­nan­cial pro­tec­tion by man­dat­ing cov­er­age for ser­vices that have pre­vi­ously been ex­cluded in some mar­kets, such as men­tal health and ma­ter­nity care.

But ad­vo­cacy groups, in­clud­ing na­tional or­ga­ni­za­tions for pa­tients with can­cer, heart dis­ease, di­a­betes and mul­ti­ple scle­ro­sis, are urg­ing state in­sur­ance com­mis­sion­ers to pay close at­ten­tion to health plan de­tails, which may still cap ben­e­fits based on the cost or num­ber of ser­vices, such as phys­i­cal ther­apy, ra­di­a­tion ther­apy and chemo­ther­apy.

For pa­tients—low-in­come pa­tients in par­tic­u­lar—who re­quire fre­quent or spe­cialty ser- vices, ben­e­fit re­stric­tions could leave house­holds with un­ex­pected and sub­stan­tial med­i­cal bills, plac­ing the pa­tient “in a very pre­car­i­ous po­si­tion,” said Stephen Fi­nan, se­nior di­rec­tor of pol­icy for the Amer­i­can Can­cer So­ci­ety Can­cer Ac­tion Net­work, one of four groups that sur­veyed the state in­sur­ance com­mis­sion­ers.

For hos­pi­tals and med­i­cal groups, that could mean con­tin­ued write-offs from un­paid bills de­spite the ex­pan­sion of in­sur­ance cover- age, in the event that ben­e­fit re­stric­tions leave house­holds “un­der­in­sured.”

The un­der­in­sured—those with ben­e­fits that fail to pro­tect against the fi­nan­cial strain of med­i­cal bills—typ­i­cally spend more than 10% of their in­come on med­i­cal care, though for low-in­come house­holds, the thresh­old is of­ten con­sid­ered 5% of house­hold in­come.

A new wave of un­der­in­sured in­di­vid­u­als could also un­der­mine the health­care in­dus­try’s push to bet­ter co­or­di­nate care and help pa­tients avoid costly and harm­ful com­pli­ca­tions. The un­der­in­sured are more likely to skip tests, med­i­ca­tions and fol­low-up vis­its than those with more gen­er­ous ben­e­fits.

Health in­sur­ers typ­i­cally have lim­ited op­tions to man­age the ben­e­fits’ price, or pre­mium, Fi­nan said, adding that in­sur­ers may in­crease de­ductibles and other cost-shar­ing for house­holds or re­duce ben­e­fits to man­age costs.

As the coun­try at­tempts to de­fine for the first time which health ben­e­fits are con­sid­ered es­sen­tial, ad­vo­cacy groups are con­cerned that re­stric­tions on ser­vices needed by the sick­est pa­tients will be ar­bi­trar­ily lim­ited to con­trol pre­mium costs. Fi­nan said ad­vo­cates hope to raise aware­ness among in­sur­ance com­mis­sion­ers and con­sumers of a “crit­i­cally and non­trans­par­ent set of prob­lems that ex­ist in health in­sur­ance.”

In Wash­ing­ton state, one of the first to se­lect a bench­mark plan, in­sur­ance of­fi­cials se­lected Re­gence In­nova to be the bench­mark for ser­vices. The plan was iden­ti­fied by con­sul­tants hired by the state as the lean­est of 10 op­tions. The con­sul­tants found vari­a­tion among the 10 op­tions on lim­its for ser­vices such as home health; some providers limit care to 130 vis­its a year and oth­ers cap care at 25 vis­its of two hours.

Cassie Sauer, a spokes­woman for the Wash­ing­ton State Hospi­tal As­so­ci­a­tion, said the Re­gence In­nova plan in­cludes ben­e­fits al­ready man­dated by the state and sup­ported by hos­pi­tals, such as ma­ter­nity care, hospi­tal stays and men­tal health­care.

“It ap­pears to me that they have done a good job se­lect­ing a plan that is not so rich or com­pre­hen­sive as to ren­der it un­af­ford­able but also that re­ally cov­ers the es­sen­tial ser­vices,” she said.

Of­fi­cials with Vir­ginia Ma­son Med­i­cal Cen­ter, a 248-bed hospi­tal in Seattle, are an­a­lyz­ing the plan, a spokesman said.

Karen Davis, Com­mon­wealth Fund pres­i­dent, said that for most fam­i­lies, the ser­vices most re­quired—hos­pi­tals, physi­cian vis­its and pre­scrip­tion drugs—will be cov­ered by in­sur­ance, though there are al­ways pa­tients who need more care. She said ben­e­fit lim­its may be one way newly in­sured pa­tients meet with un­ex­pected costs but that pa­tients may also see unan­tic­i­pated ex­penses if an in­surer’s net­work of ap­proved providers is lim­ited.

Sara Collins, se­nior vice pres­i­dent at the Com­mon­wealth Fund, told Congress in 2009 that nearly one in five un­der­in­sured adults re­ported lim­its on the num­ber of physi­cian vis­its per year. That fig­ure was roughly one in 10 among adults with more gen­er­ous cov­er­age.

And the bench­mark plan se­lected by each state will serve as a guide, not the rule, for other in­sur­ers in the mar­ket, which means con­sumers must care­fully com­pare ben­e­fits that likely will vary, said Sab­rina Cor­lette, a re­search pro­fes­sor at Ge­orge­town Univer­sity Health Pol­icy In­sti­tute.

“There’s sort of a thou­sand and one dif­fer­ent ways they could vary,” she said.

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