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HHS's essential health benefits bulletin is less than two months old--in fact, the comment period just closed this week, click here for our comment letter--but some states are already planning for what it could mean for their residents.

The Bulletin indicates that states will be able to choose the core of their essential health benefits package by copying the benefits from one of ten existing health plans.  That immediately raises the question--what do those ten plans cover? And which one would be best for kids, families, and all health insurance consumers?

Answering these questions will be complex, but a great way to start is to look at the ten plan choices side-by-side to compare what they cover.  In Maine, the Department of Insurance has put together a helpful table that compares coverage across plans in some key benefit categories.  It's by no means a complete analysis, but it's a great way to begin this important comparison.

Have you seen a similar document in your state?  If not, it could be something to ask your state's insurance regulator to put together.  Of course, you'll still want to make sure that the full plan documents that provide detailed coverage information are released publicly for each of the potential benchmarks before your state's selection is made.  But getting the plan comparison underway with a summary table like Maine's can be a good way to get started--the Bulletin says states should choose their benchmark plans by the third quarter of this year.      

Editor's Note: This is the fourth blog in a series on essential health benefits.

As legislative sessions are kicking off, it will be interesting to see which states take steps towards implementing the Affordable Care Act (ACA) this year. A new report from the Urban Institute and the Robert Wood Johnson Foundation shows that those states that have been moving most slowly on reform are also the one's whose residents have the most to gain from it.

The study divides the states into three groups:

1. Group 1 includes the 15 states that have either established an exchange through legislation or an executive order. {They are: CA, CO, CT, DC, HI, IN, MD, MA, NV, OR, RI, UT, VT, WA, and WV.}

2. Group 2 is made up of the 21 states that, while not having established an exchange, have demonstrated interest in doing so, such as by receiving an establishment grant. {They are: AL, AZ, DE, ID, IL, IA, KY, ME, MI, MN, MS, MO, NE, NJ, NM, NY, NC, PA, TN, VA, and WI.}

3. Group 3 represents those 15 states that don't fit into either of the above groups (although 9 of these states have made progress by setting up a study or planning group). {They are: AK, AR, FL, GA, KS, LA, MT, NH, ND, OH, OK, SC, SD, TX, and WY.}

Let's start with the uninsured - Group 1 and Group 2 are expected to see similar declines in the number of uninsured people following implementation of the ACA. Group 3 states start with a higher baseline of uninsured, but are expected to see a greater decrease (in almost all cases, exceeding 50%) in the number of uninsured than states in Groups 1 or 2.

Group 3 is also expected to see the largest gain in the number of people covered by Medicaid or CHIP (an overall increase of 54%), while Groups 1 and 2 see an increase of about 30%. Enrollment among those who are currently eligible is expected to increase by 1 to 2 percentage points across all states, regardless of which group they fall into. (As always, there is variation among the states within each group).

The gains in coverage through the exchanges are comparable across groups; however, Group 3 will have the largest share of their population receiving subsidies and a higher per capita subsidy relative to the other two groups of states.

With their residents having the most to gain in terms of affordable coverage for themselves and their families - it will be interesting to see whether the states in Group 3 pick up the pace or whether residents will have to wait for the federal government to step in instead?

It's a busy month on the essential health benefits front!  As we've noted, one option for states under the proposed approach for state-defined EHB packages is to use one of the state's three largest small group plans as a benchmark.  It's been difficult to evaluate this proposal because we didn't know which plans were the three largest in each state--even state insurance commissions don't always have this information.

Well, on Wednesday, HHS released a list of what it believes to be the three largest small group plans for every state.  It relies on data insurers submitted to Healthcare.gov from June of 2011.  The list comes with many disclaimers, so we can't take it as the official small group choices for states, but it's a start.

This info is useful to have, but we still need to know more about these plans to fully evaluate the EHB proposal.  We need to know exactly what the plans cover and what they exclude.  The list of plan names from HHS at least gives us a place to start in digging up that information. 

We have been offering our insights on essential health benefits through a series of blog posts.

This post is to alert you that Georgetown CCF has drafted a letter in response to the Bulletin issued by HHS in December.  We raise a number of concerns with the Bulletin's approach to essential health benefits and ask that HHS made a number of changes to better protect benefits for children and their families.  The letter asks HHS to:

* Ensure children's needs are taken into account--The benchmark plans identified in the bulletin are predominately employer-based plans.  We think states should have an option to choose a benefit package that has been designed with children's developmental needs in mind, like Medicaid's EPSDT benefit.

* Define pediatric services as including but not limited to oral and vision care--While the Bulletin discusses only oral and vision care for kids, we believe there are other services, like speech therapy or more frequent durable medical equipment, that Congress intended children to receive under this category of services it included as a requirement for the EHBs.

* Define medical necessity--Since a determination of medical necessity will affect whether a child can access the essential health benefits, we believe it is crucial for the Secretary to set a standard definition of this concept that insurance plans must follow.

* Limit insurer flexibility--The Bulletin suggests that insurers would have the authority to alter the essential health benefits.  We believe this will take away a key feature of exchange--apples-to-apples comparisons between plans.

* Assure a transparent process of benchmark selection and updating--Ensuring meaningful opportunities for public participation will be key to protecting the interests of children, families, and all insurance consumers. 

We plan to submit the letter by the date for responses provided in the Bulletin:  Tuesday, January 31.  We encourage other organizations to provide comments, as well, and if you would like to use our letter for inspiration or outright copying, please do so!  Remember, too, that since HHS explained its approach in a Bulletin rather than a formal proposed rule, it can still consider comments that come in after the January 31 date.  But don't wait too long as there will be no shortage of health reform guidance and rulemaking filling all of our inboxes in the months ahead.

There are people in my family who think I am unduly obsessed with Tom Brady.  They might even accuse me of co-authoring a paper on states at the forefront of covering our nation's children that features Massachusetts just so I could say "Just as Tom Brady is in a league of his own when it comes to quarterbacking, the Commonwealth of Massachusetts is the clear national leader when it comes to covering children." But, the honest-to-goodness truth is that the new paper we issued yesterday with the Kaiser Commission on Medicaid and the Uninsured, "Secrets of Success: An Analysis of Four States at the Forefront of the Nation's Gains in Children's Health Coverage," grew out of a discussion that CCF and Kaiser Commission on Medicaid and the Uninsured staff had together last spring.  It took place long before Tom Brady beat Tim Tebow and the Denver Broncos (soundly, I must add) and resulted in a paper that examined Massachusetts, but also three other states -- Alabama, Iowa and Oregon -- that are at the forefront of covering children.

Here is how it started.  We were discussing the news that Massachusetts had achieved a 99.5 percent coverage rate among children in 2010 and commenting on the extraordinary nature of this achievement.  Tricia Brooks with CCF, Samantha Artiga with the Kaiser Commission on Medicaid and the Uninsured, and I decided to jump in and try to untangle how the state got there.  At the same time, we didn't want to leave it just at Massachusetts.  While it is in a league of its own, states around the country have made enormous strides in covering kids.  Indeed, as we've pointed out repeatedly at CCF, the nation now has the lowest uninsured rate of children on record despite sharp jumps in child poverty and lots of other dire economic news.  So, we selected a diverse group of four states - one state from each region of the country at the forefront of covering kids: Alabama, Iowa, Massachusetts and Oregon - to investigate the "secrets" to their success.

Even though these four states have dramatically different political and policy cultures, we heard a number of common themes when interviewing state officials and advocates from each of the four states: 

* At least one political leader in the state - and, in most instances, a number of political leaders over time - made coverage of children a top priority.

* Expansive eligibility levels for children and adoption of a broad range of simplification strategies have been key elements of achieving progress. All four states have expanded eligibility for children to 300% of the federal poverty level and have taken up many of the opportunities to streamline and simplify enrollment and renewal processes for families.

* Community partners and providers play a vital role in helping families to enroll in coverage. We heard this in each of the four states, but perhaps most strongly in Massachusetts.  Interestingly, Massachusetts lags somewhat in the extent to which it has simplified its application and enrollment process, but makes up for it in no small part by relying heavily on community partners to help people enroll in coverage.  (Hey, even Tom Brady has someone weakness - a poor running game - but he also makes up for it in other areas.)The state and advocates have a robust relationship in which they exchange information on emerging issues and ideas about how to improvement enrollment.  It also has the advantage of a strong culture of coverage, which can be directly linked to its passage of broad health reform in 2006. 

* Strong coordination between Medicaid and CHIP aid in outreach and enrollment efforts and smooth transitions between programs. Each of the four states has taken steps to promote close alignment between Medicaid and CHIP, with Massachusetts and Oregon fully unifying the two programs. 

We also talked to each of the states about where they see their remaining challenges, and what they are working on now.  In a sure sign of why they are at the forefront of covering kids, each of them had a long list of challenges they were actively working to tackle, such as the need to improve retention, to cope with ongoing growth in enrollment amidst diminishing administrative resources; updating decades-old eligibility systems; and improving communications with families and obtaining better enrollment data.  Just like Tom Brady and the New England Patriots, they do not rest on their laurels and, instead, start each week looking ahead and figuring out how to continue to get better and better.

and Tricia Brooks

For those of you who have been anxiously awaiting (and you can count us, too!) the release of the annual survey on Medicaid and CHIP, today is your lucky day.  In partnership with the Kaiser Commission on Medicaid and the Uninsured, we released "Performing Under Pressure: Annual Findings of a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost Sharing Policies in Medicaid and CHIP" at a briefing today.

Probably not surprising to those who follow such things, but we found that eligibility held steady in nearly all states, with only two states reducing eligibility. And the two that did - they did so for low-income adults relying on limited exceptions to the stability protections (otherwise known as maintenance of effort provisions of the Affordable Care Act). It's very likely that without the stability protections, more states would have made cutbacks and far more children and families would be left without an affordable coverage option during these turbulent economic times.

A far more surprising finding was the fact that 29 states went beyond holding steady and improved coverage through targeted expansions and simplifications. Most of these changes centered around the greater use of technology to boost government efficiency and make it easier for people to enroll in coverage; actions that have a dual benefit of helping eligible children and families while also stretching scarce state administrative resources.

But perhaps the most striking finding is how quickly a large number of diverse states across the country are leaping at the opportunity to make sweeping changes to their decades-old eligibility systems. More than half of the states have already sought the enhanced federal funding to develop the latest technology that will both transform families' experience of applying for health care coverage and make government work better. And, with just three exceptions, the rest of the states are planning to move in that direction in 2012.

And all this in spite of the fact that in 2011, state budgets remained stressed due to dampened revenue growth and the mid-year expiration of the temporary increase in the federal matching rate. So while strained state budgets have taken a toll on administrative resources, states have sharpened their use of technology and streamlined their procedures to create more efficient programs, while also simplifying the steps for families to enroll in and renew coverage. These actions, in addition to the massive systems upgrades they've undertaken, have not only helped states deal with current pressures, but are also laying the groundwork for the coverage expansions and new enrollment requirements that will take effect in 2014.

And let's not forget that amid these ongoing pressures, the stability protections in the Affordable Care Act were central to the preservation of health care coverage last year. So even with a weak economic recovery that has been slow to add new jobs with access to employer-based insurance, Medicaid and CHIP continued to be key sources of coverage for children, and, in some cases, for their uninsured parents. A bit of good news to start the year!

[A parting note to those who like us, want to dig in on the nitty-gritty details - there are several new areas that we report on this year (such as the use of out-stationed state eligibility workers and enhanced functionality with online accounts) all of which can be found in the full report. Enjoy!]

By Beth Morrow, The Children's Partnership 

As all health advocates know, states face a daunting task in preparing to meet the demands of ACA implementation.  Building an eligibility, enrollment, and retention system is one of the first challenges involved in getting ready for state Exchanges' open enrollment period on Oct. 1, 2013.  Deploying such a system involves more than just building the technology.  The design and development of this technology will be driven by complex policy, process, and governance decisions that states are making now.  With aggressive implementation schedules, no state has the luxury of waiting before starting to design their system.

As California proceeds through this very consequential puzzle, The Children's Partnership has written a 40-page blueprint designed to assist in that process and make sure that consumers' interests are front and center as decisions are made.  Written by Dawn Horner and myself, Building A Consumer-Driven Eligibility, Enrollment, and Renewal System: Essential Design Features for Effective Health Reform in California lays out the essential design features that are required in any state for an effective enrollment system that meets federal expectations.  In California, this new system is being called CalHEERS (for California Healthcare Eligibility, Enrollment, and Retention System).

Broadly these essential design features are:

• Smart connections that allow consumers to apply for coverage through multiple doorways (whether online, by mail or phone, or in person) and receive consumer assistance -including live human assistance--as needed.
• Integrated eligibility criteria and processes that allow every consumer to apply using a single application for all programs, and to seamlessly move between programs as family circumstances change.
• Real-time, immediate, and ongoing enrollment that utilizes technology to obtain and verify data and eliminates unnecessary paper documentation.
• Easy navigation of coverage that allows consumers to pick their health plan, pay premiums, and update their account through a centralized system.

For each design feature, the report provides specific recommendations (some very detailed, some more general), summarized as a tear sheet in the Executive Summary.  A small sampling of the report's recommendations includes:

•  Establish accuracy and timeliness standards to guarantee quality of consumer assistance.

• Eliminate the three-month waiting period for children with employer coverage for Healthy Families (California's CHIP program).

•  Automatically transfer children from 101% to 138% FPL from Healthy Families to Medi-Cal (the state's Medicaid program) and provide support to maintain continuity of care.

• Integrate human service program enrollment into CalHEERS by the end of 2015, commencing with SNAP and TANF.

•  Establish a policy that finds "incompatibility" within an application only where the inconsistent data would have a "material" impact on eligibility - i.e., would change the outcome. 

• Design the premium payment function so that consumers receive one monthly bill for the whole family. 

Our new report provides a guide for action for California, to ensure that the state gets this right, right out of the gate.  And, while written to address California's specific concerns, this report can help any state move toward a first-class consumer experience that results in individuals getting the coverage and health care they need.

So my previous blog on this topic talked about how the CHIP/Essential Health Benefits analogy has its limits - still it is interesting to look at the choices that states have made for their benefits packages in separate state CHIP programs.

According to data collected and released by NASHP from mid-2008, the most popular choice by states was to use "Secretary approved coverage" - an option that would not be available under EHB. 

Eighteen out of 40 states picked this option. Most states were using this option to provide a Medicaid look-alike package so as to simplify coordination between the two programs - an interesting finding. The second choice was to base CHIP benefits on state employee coverage - again, something with which states are familiar. Only one state has selected the federal employees benefit option - suggesting that few states will pick up this option in EHB.

Four states selected benchmark equivalent coverage.  In two of those states,  South Carolina and Utah,  the benchmark was tied to their state employee coverage and in the other two, Indiana and Wisconsin, the benchmark was tied to the largest commercial HMO.

So a bit of a hodgepodge but it seems to me that the CHIP experience suggests that few states will choose the FEHBP option and are more likely to choose an option that promotes coordination with other aspects of their state coverage picture. This could mean that many states will choose the small group option (so as to have continuity inside and outside of the exchange) or the state employee option.

This is the third in Say Ahhh's blog series on essential health benefits.

We haven't heard much about what Politico has dubbed the "sleeper issue" of the Supreme Court case because it is the least likely to be found unconstitutional.   This week, Attorney Paul Clement tried to stoke a little life into the sleeper issue by tying it to the more controversial mandate provision.  In the brief he filed on behalf of the states challenging the constitutionality of the Affordable Care Act, he argued that the Medicaid expansion is possibly more coercive than the mandate (otherwise known as the individual responsibility or minimum-insurance coverage provision).

As with most anti-Affordable Care Act arguments, the point that expanding Medicaid would be "coercive" and impose a mandate on the states is based on "more rhetoric than fact".    I would like to take credit for that phrase but I found it in the 11th Circuit Court ruling on the topic. 

"While some individuals are exempt from the penalties designed to enforce the mandate, no state is exempt from the massive penalty -- the loss of the entirety of funding under the single largest grant-in-aid programs for the states -- and so Congress did not even contemplate the possibility of a state opting out of Medicaid," wrote Clement in a brief filed with the court Tuesday.

Hopefully even that super-charged rhetoric can't wake the Rip Van Winkle of sleeper issues. 

For another viewpoint, read the New England Journal of Medicine piece "All Heat, No Light - States' Medicaid Claims Before the Supreme Court" by Sara Rosenbaum and Tim Jost.  They write:

"From a legal perspective, nothing about this latest Medicaid expansion is different from past expansions, other than the fact that it passed as part of a broader health care reform effort. This fact does not change Medicaid's fundamental status as a voluntary program. Were a state to decide that it would rather end its Medicaid program than cover poor adults, it might have to devise a health care alternative for its poorest residents. But that has always been the question states face when Congress expands Medicaid. States may be confronted with a "hard choice," in the words of the 11th Circuit, as to whether to continue participating in Medicaid. But that is not a constitutional matter."

The Department of Justice brief on the Medicaid expansion is due on February 10.  Oral arguments on the topic are scheduled for March 28.  For more information on the Supreme Court timeline and a synopsis of the friend of the court briefs filed in support of the Affordable Care Act so far, visit the Center for Progress.

By Leigha Basini, National Academy for State Health Policy

The new year brings many new things: new discussions about CCIIO's newly released Essential Health Benefits (EHB) Bulletin and benefit provisions in the seemingly still new Affordable Care Act.  But state CHIP directors may also be thinking about a slightly older benefit provision--the CHIPRA dental mandate.  NASHP, in conjunction with the Children's Dental Health Project, recently completed an issue brief for the National Maternal and Child Oral Health Policy Center on states' dental benefit changes as a result of CHIPRA, and the findings may help state CHIP programs that are still mulling over their options, state officials working on the EHB, and advocates focused on ensuring strong coverage for children.

Prior to CHIPRA, all states voluntarily offered some level of oral health benefit, but benefits varied widely by state.  CHIPRA leveled the playing field by requiring all states to offer dental coverage that meets a minimum level.  Although regulations are still forthcoming, CMS guidance gives states two options.  States may offer a state-defined benefit package with coverage of services in ten distinct categories such as diagnostic and preventive care and orthodontics.  Or, similar to the options the federal government gave states with CHIP and the EHB package, states may offer a benchmark plan.  Benchmark options include:

1. The Federal Employee Health Benefits Program dependent dental coverage that employees selected the most frequently in the past two years;

2. State employee dependent dental coverage that employees selected the most frequently in the past two years; or

3. The state dental plan with the largest commercial, non-Medicaid enrollment.

However, unlike CHIP benefit packages and EHB, benchmark plans must truly be equivalent and not just actuarially equivalent.  States may add benefits to the benchmark plans, but they may not subtract or alter the benefits that the benchmark plan provides.  On the flip side, if the benchmark plan does not cover a certain service, such as orthodontics, the state is not required to cover it in its CHIP plan. 

Of the nine states with CMS-approved State Plan Amendments (SPAs) at the time the brief was written, seven of nine chose to offer state-defined dental benefit packages as opposed to benchmark packages.  This is perhaps surprising because states opting for state-defined coverage must cover costlier services such as orthodontics that may not be required with a benchmark package.  Also, these states must cover medically necessary care that is in excess of annual benefit maximums.  However, it may actually be less costly for states to provide a state-defined package, since the benchmark packages generally require hefty cost sharing, and CHIP cost sharing is limited to five percent of a family's income, including non-dental services, too.  So, it could be rather costly for a state to provide a benchmark plan with very limited cost sharing.

The new EHB guidance gives states two options for providing pediatric dental coverage--the Federal Employees Dental and Vision Insurance Program dental plan with the largest enrollment or the benefit package in the state's CHIP program.  While we don't yet know the nuances of what this means, the apparent possibility of overlap in kids' dental benefits across CHIP and EHB coverage gives state agencies a great opportunity to collaborate and ensure a level of consistency across coverages.  For states that haven't yet selected a CHIP dental benefits package, the EHB bulletin provides an incentive for collaboration, and for CHIP programs that have already implemented their CHIP dental benefits, it gives state officials working on the EHB a great resource to call on!

Benefits are only one part of improving children's dental health, and states are looking forward to the release of the State Health Official letter regarding CMS' oral health strategy to improve utilization rates.  But CHIPRA's dental benefit is a great start for children in CHIP, as it ensures that all CHIP kids have a base level of comprehensive oral health benefits needed for strong dental and physical health and well-being.