health care reform: coverage expansion …...2010/05/13 · health care reform: coverage expansion...

Health Care Reform:Health Care Reform:Coverage Expansion andCoverage Expansion andCoverage Expansion and Coverage Expansion and

Dental BenefitsDental BenefitsMay 13, 2010

OVERVIEWToplineToplineHealth reform coverage requirementsCoverage expansionCoverage expansion‐ Medicaid‐ Insurance expansionInsurance expansion

Essential benefits and dentalSubsidies and dentalSubsidies and dentalNADP actionsDefining ‘essential benefits’Defining essential benefits

May 13, 2010 2NADP Member's Internal Use Only / Do Not Distribute

COVERAGE EXPANSIONCOVERAGE EXPANSION

Carole JohnsonCarole Johnson


TOPLINE FOR DENTAL‘Children’s pediatric oral health services’ is a requiredChildren s pediatric oral health services is a required ‘essential health benefit’ in the individual and small group market.

Bill originally envisioned this coverage being the responsibility of medical plans.

Changed by amendment to allow stand‐alone dental plans to provide required kids’ dental coverage directly in the new Health Insurance Exchangesthe new Health Insurance Exchanges.

Becomes a medical plan responsibility in the individual and small ro p market o tside of the E han esand small group market outside of the Exchanges.


PPACA STRUCTUREAll Americans must have minimum essential coverage

Minimum Essential Coverage

All Americans must have minimum essential coverage


Individual or small group health plan

Other coverage recognized by the Secretary of HHS

Large group health plan

Government programs: Medicare, Medicaid, CHIP, VA, TRICARE


PPACA COVERAGE FOCUSPPACA COVERAGE FOCUSInitially, coverage expansion provisions focus on: y, g p pindividual/small group markets and Medicaid


Individual or small group health plan

Other coverage recognized by the Secretary of HHS

Large group health plan

health plan Secretary of HHS

Government programs: Medicare, Medicaid,health plan Medicare, Medicaid, CHIP VA, TRICARE


COVERAGE EXPANSIONCBO estimate: Health reform will cover 92% of the populationHealth reform will cover 92% of the population.

Net 32 million gain coverage.

Medicaid expansion = 16 million lives

Health Insurance Exchanges = 24 million lives


M k I f EHBPMarket Impact of EHBP

Added Pvt. Mkt. CoverageOf 24 million in Exchanges

??? million children

TODAY: 1.65 million small employers20 8 illi l

Not Directly Impacted Impacted

May 13, 2010 8

20.8 million employees 22.9 million dependents

NADP Member's Internal Use Only / Do Not Distribute

MEDICAID


MEDICAID EXPANSIONBeginning in 2014, states are required to provide Medicaid g g , q pcoverage to individuals under 65 with incomes up to 133% of poverty.

Newly eligible are fully funded by the federal government until 2016 (federal/state cost‐sharing phases back in).

The benefit package is “benchmark” or “benchmark‐equivalent” coverage rather than traditional Medicaid benefits.

States have the option to begin this coverage expansion inStates have the option to begin this coverage expansion in 2011 (but enhanced match doesn’t begin until 2014).


Household Incomes of AmericansHousehold Incomes of Americans with Dental Benefits

34.5%

11.3%

4.1% 10 0%4.1%

2.7%1.4%1.8%

10.0%

44.2%Could be impacted by 44.2%p yMedicaid Expansion

<$50K $50‐$99K $100K‐$124K $125K‐$149K $150K‐$175K $175K‐$199K $200K+


INSURANCE EXPANSIONINSURANCE EXPANSION


ENHANCING INSURANCE OPTIONSGoal: Require more robust coverage in the individual and small group markets.

Essential health benefits package: Beginning in 2014, all new coverage in the individual and small group market must include the “essential health benefits package.”

Prevention: All new plans are required to cover, without cost‐sharing, recommended preventive

iservices.May 13, 2010 13NADP Member's Internal Use Only /

Do Not Distribute

NOTE: Key Definitions“Small group” means at least 1 but not more than 100 employees.

U il 2016 l d fi ll l 1 b‐ Until 2016, state can elect to define small as at least 1 but not more than 50 employees.

• “Grandfathered plans” means coverage an individual is enrolled in on date of PPACA enactment (3/23/10). Individuals can continue to enroll family membersIndividuals can continue to enroll family members. Employers can continue to enroll new employees and dependents. Full definition to be established in regulation.


EXPANDING INSURANCE OPTIONSEXPANDING INSURANCE OPTIONSGoal: Create a mechanism for individuals and small groups to get the insurance pool purchasing power of a larger group.

Health Insurance Exchanges: By 2014, each state will create Exchanges to allow individuals and employers under 100 to access more affordable coverage options. (State100 to access more affordable coverage options. (State option to allow large employers after 2017.)

Exchanges are allowed to charge health insurers user feesExchanges are allowed to charge health insurers user fees.

Health plans in the Exchanges have to offer the essential h lth b fit khealth benefits package.


ESSENTIAL HEALTH BENEFITSESSENTIAL HEALTH BENEFITS


ESSENTIAL HEALTH BENEFITS REQUIREDESSENTIAL HEALTH BENEFITS REQUIRED

Exchange

ExchangeIndividual andIndividual andSmall Group Markets


ESSENTIAL HEALTH BENEFITS PACKAGEIncludes:

d ‘ l h l h b f ’Required ‘essential health benefits’‐‐Scope of benefits must equal ‘typical’

l demployer‐sponsored coverageOut‐of‐pocket limits

d bl l f llDeductible limits for small group coverageActuarial value requirements


ESSENTIAL HEALTH BENEFITS PACKAGEESSENTIAL HEALTH BENEFITS PACKAGEEssential health benefits: Categories identified in law; specifics to be defined by HHS Secretary.

Ambulatory patient services.Emergency services.Hospitalization.Maternity and newborn care.Mental health and substance use disorder servicesMental health and substance use disorder services.Prescription drugs.Rehabilitative and habilitative services and devices.Laboratory services.Preventive and wellness services and chronic disease managementmanagement.Pediatric services, including oral and vision care.


ESSENTIAL HEALTH BENEFITS PACKAGE

Out‐of‐pocket limits: Limits allowable cost‐sharing. In 2014, EHBP cost‐sharing is limited to the out‐of‐pocket limit for HSAs ($5,950 indiv/$11,900 family).

Deductibles: Generally small group coverage cannotDeductibles: Generally, small group coverage cannot have a deductible exceeding $2k for indiv/$4k for other coverage. Deductible cannot apply to g pp ypreventive services.


ESSENTIAL HEALTH BENEFITS PACKAGE

Actuarial values: Coverage must be offered at specific AVs (as a share of the full AV of the essentialspecific AVs (as a share of the full AV of the essential health benefits):

Bronze = 60% AVBronze 60% AVSilver = 70% AVGold = 80% AVGold = 80% AVPlatinum = 90% AV


ESSENTIAL BENEFITS & DENTALESSENTIAL BENEFITS & DENTAL


OUTSIDE OF EXCHANGES

Beginning in 2014, health plans in the individual and small group market including those offered outside ofsmall group market ‐‐ including those offered outside of the Exchanges ‐‐ will have to provide all essential health benefits, including kids’ dental.g


INSIDE THE EXCHANGESStand‐alone dental plans are allowed to directly sell the required kids’ dental benefits.

A medical plan must offer all essential benefits –including dental – to sell in the Exchange.

f d l d l l ff h d‐ Except, if a stand‐alone dental plan offering the required kids’ dental is available in an Exchange, a health plan without kids’ dental that has all of the other essential benefits is allowed to offer coverage in the Exchange.

• Likely applicable of new market reforms to this coverage• Likely applicable of new market reforms to this coverage by regulation.


Survey QuestionWill your company offer children‐only dental policies?

Our company already offers child‐only policiesYes, our company will be offering child‐only policies in the future Our company is considering offering child‐only policiesOur company is considering offering child only policies Our company has not discussed offering child‐only policiesNo

May 13, 2010 25

SUBSIDIESSUBSIDIES


SUBSIDIES IN THE EXCHANGES

Premium subsidies are available on a sliding scale up to 400% of poverty to help make coverage more affordable400% of poverty to help make coverage more affordable in the Exchanges.

Cost‐sharing assistance for deductibles, copays, coinsurance, etc. also available on a sliding scale up to 400% f t400% of poverty.


SUBSIDIES AND DENTALIf i di id l ll i b h lifi d h l h l dIf an individual enrolls in both a qualified health plan and a dental plan with required kids’ coverage, the premium for dental benefits is treated as a qualified health planfor dental benefits is treated as a qualified health plan premium when subsidies are calculated.

C t h i i t i l d i l l fCost‐sharing assistance includes a special rule for individuals who get required kids’ dental from a stand‐alone plan not a health plan. The portion of cost‐sharing p p p gassistance that would be allocable to dental benefits in the health plan does not apply. Allocation to be d t i d i l tidetermined in regulation.


NADP ACTIONSNADP ACTIONS

Evelyn Irelandy


NADP ACTIONSHouse dental amendment‐ Adopted in committee, not in final House bill

Senate dental amendmentSenate dental amendment‐ Adopted in committee, partially included in final Senate bill and final PPACA law

‐ Added option for dental to sell required benefits directly in the Exchange

Ongoing efforts to allow dental to sell required benefits directly in the individual and small group market outside the Exchanges.


DEFINING ESSENTIAL BENEFITSDEFINING ESSENTIAL BENEFITS


hild ' l hChildren's Health Insurance Program (CHIP) ( )

Dental Coverage‐‐children up to age 19 toprevent disease and promote oral health, p p ,restore oral structures to health and function, and treat emergency conditions for all children


CHIP (cont.) Benefit Level Options

Benchmark dental coverage or equivalentBenchmark dental coverage or equivalentCoverage that is substantially equal to

FEDVIP, State Employee dental orthe State’s largest commercial dental plan


Model Dental Benefits PlanAmerican Association of Pediatric Dentists (AAPD)

Children up to age 21Based on

2009/2010 AAPD Reference ManualGuide to Clinical Preventive ServicesGuide to Clinical Preventive ServicesBright Futures in Practice: Oral Health

Incorporates new Caries Risk Assessment ToolRequires Behavior Guidance & Education


AAPD M d l D t l B fit PlAAPD Model Dental Benefits Plan(cont.)

Full Range of Procedures forDiagnostic & Preventive including Education g gRestorative—Fillings & CrownsEndo, Perio, Prostho (includes Implants)Oral surgeryOrthodonticsDrugs, Adjunctive Services


fi i di iDefining Pediatric CoverageNADP Next Steps…p

Professional Relations Council (PRC) Review of ModelsM k t S t D t i C t P di t i CMarket Survey to Determine Current Pediatric CoverageHCR Task Force Recommendation/Board Approval


health care reform: coverage expansion …...2010/05/13 · health care reform: coverage expansion...

Documents