Illinois to decide on essential health benefits

Bloomberg Businessweek reports:

“Gov. Pat Quinn has less than a month to choose which benefits will be required in basic health insurance plans sold to individuals and small businesses in Illinois under the federal health care law, an important decision that will determine the cost of future premiums and how broad coverage will be for many patients.

As the presidential election focuses on President Barack Obama’s national health care overhaul, Illinois has been inching toward implementing the law. Although the governor hasn’t been able to push through some needed legislation, he doesn’t need the Legislature to OK his choice of a benchmark to assure that Illinoisans receive “essential health benefits.”

Illinois is behind only nine other states that have already chosen a benchmark plan or have a preliminary recommendation, according to a nonpartisan group tracking state progress on the law. The deadline for states to select those basic plans is Sept. 30.

“Illinois is pretty much on track with a lot of other states” on essential health benefits, said Sonya Schwartz of the National Academy for State Health Policy. “For the most part, this is a temporary decision and is about keeping the market stable.”

The federal health law set 10 basic categories that must be covered by health plans, such as emergency services, prescription drugs and maternity care. But within those categories, states have flexibility to determine a basic level of covered services and costs.

For instance, should acupuncture be covered? Weight loss surgery? Hearing aids? Routine eye exams?

Choosing a benchmark plan that covers acupuncture doesn’t mean that all plans in Illinois would have to cover it. But the health plans would have to provide benefits of equal actuarial value, so they could trade coverage of another service of equal value for acupuncture.

States will select one existing health plan to serve as a benchmark or guide. If states don’t choose a benchmark, the federal government steps in to name an existing popular small group plan in the state as the default benchmark.

Each covered service adds to the cost of insurance premiums, so Quinn — who strongly supports the law championed by his fellow Democrats — and a group of state officials working on the decision will consider affordability as they choose a benchmark plan.

Public comment also will be considered, and a three-hour meeting to gather public input will be held Wednesday at 3 p.m. in Chicago’s Thompson Center and by teleconference in Springfield at the Stratton Building, next to the Capitol.

A chart comparing 10 potential benchmark health plans is posted on the governor’s health reform website. Federal regulations require the essential benefits to match those offered in one of the state’s most popular health plans already available to Illinois residents.

Quinn intends to choose a benchmark plan by the Sept. 30 deadline, said Colleen Burns of the Illinois Department of Insurance. She leads the state team working on the online health insurance marketplace where consumers will be able to shop for health insurance starting next fall.

The national law exempts large-group health plans from the requirement to provide the essential health benefits. But plans sold to individuals and small businesses — whether sold within or outside of the online exchange — must provide the essentials.

None of the potential benefit plans on the governor’s website cover children’s dental or vision care, which is a federal requirement, Burns said. That means the state will have to designate another plan to supplement the benchmark in those areas.

The work group that will make a recommendation to Quinn has set some goals, Burns said. The benchmark plan should cover all the state’s existing mandates, for example, such as requirements for insurance coverage of infertility and autism treatments.

Liz Klug, executive director of the Chicago-area chapter of Autism Speaks, is organizing a group to attend the public meeting. She said it’s important that Quinn choose a benchmark plan that clearly spells out that policyholders have “access to all the behavioral therapies, speech therapies, occupational therapies and other medically necessary therapies for people with autism.”

Comprehensive coverage and affordability will be considered, Burns said. “It’s a balancing of the two,” she said. The group also will consider market stability. For example, choosing an extremely lean health plan as a benchmark could leave other health plans with greater risk because sicker people would choose them for the broader coverage of health services they need.

People with diseases such as cancer should care about the benchmark plan choice, said David Woodmansee of the American Cancer Society Cancer Action Network. Limits on the number of covered doctor visits, for example, need to be reasonable, he said.

“We don’t want to see limits that are unrealistic for treatment of cancer patients,” Woodmansee said. “What we’re looking for is some reasonableness and decent consumer protections that allow people to access care when they need it.””