1. Vermont Health Insurance Benefits:
Essential Health Benefits Analysis,
Part II
The Vermont Exchange Advisory Group
February 27, 2012

2. Agenda
Review of EHB / Requests
Update on Benefit Restrictions
Prior Authorization
Missing Services in Categories
Required by the ACA
Standardized Summary of Benefits
2

3. Requests for Additional Information
At the last Exchange Advisory Committee Meeting and
the Green Mountain Care Board Meeting, requests
were made for more information about:
 Benefits Restrictions
 Prior Authorization
 Options for supplementing plans when categories are
missing
 Since then, we have also received additional
guidance from HHS

4. Reviewing EHB: Use of a Benchmark
Plan
 EHB will be defined by a benchmark plan selected by
each state.
 HHS Update: The benchmark chosen in 2012 will apply
for both years 2014 and 2015.
 The plans offered in the state must be “substantially
equal” to the benchmark plan.
4

5. Reviewing the EHB Options:
 Potential Options in Vermont:
– Largest small group plans
• MVP – Preferred exclusive provider plan (CY11 Q4: 7,414)
• BCBSVT – BlueCare (estimate for CY12 Q1: 7,201)
– Largest HMO
• BCBSVT (~31,000 enrolled; benefits are generally the same as
in small group)
– State employee plan (administered by Cigna)
 Did not consider the federal employee health benefits
plan
HHS Update: plans to provide States with a list of the top three small
group market products in each State based on data from
HealthCare.gov from the first quarter of the 2012 calendar year.

6. Agenda
Review of EHB / Requests
Update on Benefit Restrictions
Prior Authorization
Missing Services in Categories
Required by the ACA
Standardized Summary of Benefits
6

7. Update on Benefit Restrictions
 Under the intended approach, a plan must be
substantially equal to the benchmark plan, in both the
scope of benefits offered and any limitations on those
benefits such as visit limits.
 A plan could substitute coverage of services within each
of the ten statutory categories, so long as substitutions
were actuarially equivalent.

8. HHS Update: Process for Determining
Equivalence
Relies on an actuarial report that:
 Uses a standardized set of utilization and price factors
and population;
 Applies the same principles and factors in comparing the
value of different coverage;
 Does not take into account any differences in coverage
based on the method of delivery or means of cost control
or utilization used; and
 Takes into account the ability of a plan to reduce benefits
by considering the increase in actuarial value of health
benefits coverage offered that results from the limitations
on cost sharing (with the exception of premiums) under
that coverage.

9. The overall amount of restrictions is
important, the specific details are not
 The specific types of restrictions matter less than the
overall amount of restrictions because the plans have
the flexibility to change the specific restrictions (add
some new ones and remove others entirely) as long
as they maintain actuarial equivalence.
 Example from HHS: A plan could offer coverage
consistent with a benchmark plan offering up to 20
covered physical therapy visits and 10 covered
occupational therapy visits by replacing them with up
to 10 covered physical therapy visits and up to 20
covered occupational therapy visits, assuming
actuarial equivalence and the other criteria are met.

10. Agenda
Review of EHB / Requests
Update on Benefit Restrictions
Prior Authorization
Missing Services in Categories
Required by the ACA
Standardized Summary of Benefits
10

11. Prior Authorization
 See handout

12. Agenda
Review of EHB / Requests
Update on Benefit Restrictions
Prior Authorization
Missing Services in Categories
Required by the ACA
Standardized Summary of Benefits
12

13. ACA Requires That EHB Include Services
Within 10 Categories
 Ambulatory patient  Prescription drugs
services  Rehabilitative and
 Emergency services habilitative services and
 Hospitalization chronic disease
 Maternity and newborn management
care  Laboratory services
 Mental health and  Preventive and
substance use disorder wellness services
services, including
behavioral health  Pediatric services,
treatment including oral and vision
care
13

14. Missing Services
 If benchmark plan does not include coverage for all
10 categories, state must supplement the missing
categories with the benefits from another benchmark
option
– habilitative services
– pediatric oral
– pediatric vision
– prescription drugs
 HHS Update: HHS intends to propose that if benefits
in a statutory category are offered only through the
purchase of riders in a benchmark plan, that required
EHB category would need to be supplemented by
reference to another benchmark plan option

15. The plan selected will determine which
“Missing” services you need to fill
Categories MVP BCBSVT State Plan
Habilitative
Services
Pediatric Vision
Limited benefits Limited benefits
Included Included
Pediatric Oral
Prescription Included
Drugs (no choice)

16. Habilitative Services:
No Separate Decision Required
Update from HHS:
 HHS will either:
– Require plans to offer the same services for habilitative
needs as it offers for rehabilitative needs and offer them at
parity.
 Or
– A plan would decide which habilitative services to cover and
report the coverage to HHS. HHS would evaluate and further
define habilitative services in the future. Under either
approach, a plan would be required to offer at least some
habilitative benefit.

17. Defining Habilitative Services: MVP
MVP’s Definition:
 focus exclusively on medical benefits and not expand
medical benefits to include social or educational
services traditionally not covered by health
insurance. These medical services could include
physical therapy, occupational therapy and speech
therapy, as examples of "medical" habilitative
services.
 Also utilize reasonable service limitations (such as
visit limits), medical management tools and
requirements regarding provider licensure.

18. Defining Habilitative Services: BCBSVT
BCBSVT’s Definition:
 Rehabilitative services are health services intended
to relieve pain, restore physical function, or improve
psychological function where pain or functional
impairments result from disease, injury or loss of
body part.
 Habilitative services are health services that aim to
achieve physical or psychological function impaired
by congenital or developmental conditions that
prevent normal function, whether normal function was
initially present or not.

19. Defining Habilitative Services: State Plan
 The state plan does not currently cover habilitative
services and was unable to provide us with a
proposed definition of habilitative services.

20. Vision Care in the Plans
Unclear whether they provide enough coverage to “count” as
services within the category
Services BCBSVT State Plan
Routine Vision Exam $100 to use towards
(Refraction) One annual exam vision services every
24 months*
Eyeglasses and Contact May use the $100
Lenses towards lenses*
Replacement of
eyeglasses or contact
lenses, in whole or in
part
Frames
*since dollar limits are not allowed under the ACA, benefit with dollar limits will be
incorporated into the EHB definition without the dollar limit.

21. Pediatric Vision Care:
No Separate Decision Required
 If the plans are “missing” pediatric vision care, HHS is
considering proposing that the State would
supplement the plan with the benefits covered in the
FEDVIP vision plan with the highest enrollment.

22. Pediatric Oral Care:
Decision will be Required
All of the plans are missing services in the Pediatric
Oral care category.
HHS is considering proposing that the State would
supplement the benchmark plan with benefits from
either:
– The Federal Employees Dental and Vision Insurance
Program (FEDVIP) dental plan with the largest national
enrollment; or
– The State’s separate Children’s Health Insurance Program
(CHIP).

23. Prescription Drugs:
Decision will be Required
 State Options:
– State Employee Plan
– Federal Employees Health Benefits Plan
 If a benchmark plan offers one drug in a certain category
or class then all the plans in the small group and individual
market must cover at least one drug in that category or
class
 The drug category and class lists will be provided by the
U.S. pharmacopoeia, AHMS or other standard. (not
available yet)
 Recommend waiting for further direction from HHS
regarding the classes and categories before conducting
the comparison

24. Agenda
Review of EHB / Requests
Update on Benefit Restrictions
Prior Authorization
Missing Services in Categories
Required by the ACA
Standardized Summary of Benefits
24

25. ACA Requires Standardized Summary of
Health Insurance Benefits
 CCIIO released two forms on February 9, 2012
– Drafted with assistance of National Association of Insurance
Commissioners (NAIC)
 Summary of Benefits
– Includes information on cost-sharing
– Includes information by category of service
• In/out of network providers
• Service limitations
 Uniform Glossary of Benefits
– Standard definitions for common health coverage terms
• Examples: co-insurance, emergency room care, balance billing