Two of Governor Tom Wolf’s priorities are that his
administration be open and transparent and that it work to make health care
more accessible to Pennsylvanians across the Commonwealth.
To further those goals, I am asking for your input as the
state considers an important recommendation to the federal government that can
help shape our health care future.
The Affordable Care Act (ACA) requires that individual and
small group health care plans cover a set of services, which are known as
“essential health benefits” (EHB). These benefit packages must include specific
coverages, including ambulatory patient services; emergency services;
hospitalization; maternity and newborn care; mental health and substance use
disorder services, including behavioral health treatment; prescription drugs;
rehabilitative and habilitative services and devices; laboratory services;
preventive and wellness services and chronic disease management; and pediatric
services, including oral and vison care.
Because the state did not choose a package for consumers
back in 2012, Pennsylvania’s current plan was selected for us by the federal
government. The current benchmark plan may be viewed
here. However, looking forward to 2017, we now we have the chance to
make a collective choice that best fits families and consumers throughout the
state.
If Pennsylvania does not make a recommendation, the federal
government will once again select our benchmark plan. In this case, our package
would be the Keystone Health Plan East option.
Essential Health Benefit Benchmark Plan Options
With that in mind, below are the options that we have to
choose from:
The three largest plans by enrollment in any small group
insurance product in Pennsylvania’s market:
The largest three state health benefit plans by
enrollment. These three plans all have the same benefit package, although
coverage limits differ on a few services between the PPO/CDHP plan design and
the HMO plan design. Because both PPO and HMO plans are in the three largest
plans by enrollment, please consider both plan designs:
The largest three national health benefit program plans:
The largest commercial non-Medicaid HMO operating in
Pennsylvania:
Essential Health Benefit Benchmark Plan Pediatric,
Dental, and Vision Supplementary Options
If the selected benchmark plan does not cover pediatric oral
services, the benchmark plan must be supplemented by the FEDVIP (federal
employees') dental plan with the largest national enrollment or the Title XXI
CHIP plan in Pennsylvania with the larges enrollment. These two plans are:
If the selected benchmark plan does not cover pediatric
vision services, the benchmark plan must be supplemented by the FEDVIP (federal
employees') vision plan with the largest national enrollment or the Title XXI
CHIP plan in Pennsylvania with the largest enrollment. These two plans are:
Essential Health Benefit Benchmark Plan Options
Comparison Chart
To assist in review and comparison of these options, the
Pennsylvania Insurance Department prepared a chart that presents a preliminary
summary overview of the benefits available under the current benchmark plan and
the options for the new benchmark plan. Note that this chart is not a
substitute for the complete plan materials; it does not reflect a complete list
of every benefit, benefit limit, or other service limit that may be included in
any of the plans. This summary should not be relied on in place of your own
analysis of the plan materials, and you should reference the plan documents for
exact details of each plan.
Invitation for Comment
In order to assist us in evaluating these plans and
developing a recommendation, we invite public comment on all these options.
These comments may consider, for each plan’s benefit package, things like: the
impact on particular populations, including vulnerable citizens; the
flexibility and innovation in plan design by different insurance companies that
may be lost or gained, and the potential cost of going with a specific option.
We particularly invite comment on the habilitative benefits available in the
benchmark plan options and solicit comments on a possible state definition of
habilitative services in the event that the selected benchmark plan does not
include habilitative services
.
Beca
use the federal government requires Pennsylvania’s
recommended selection by July 1, 2015, the comment period will only remain open
until June 12th. We invite you to send your comments to ra-in-press@pa.gov.
Thank you again for your help in shaping Pennsylvania’s
health care future.
Teresa Miller
Insurance Commissioner
