Essential Health Benefits Balancing Coverage and Cost (2012) / Chapter Skim
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7 Program Monitoring and Research
7 Program Monitoring and Research
Pages 115-128
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From page 115... ...
contains numerous ele ments that require monitoring, research, and oversight, such as the implementation of health insurance exchanges or expansion of the traditional Medicaid program. The EHB are just one of many areas requiring attention by HHS.
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From page 116... ...
The state and federal health insurance exchanges are responsible for determining which health plans are qualified to operate in the exchange and can serve as a primary data source for what is happening across states and over time in response to the Secretary's guidance. The EHB are also required for incorporation in all non-grandfathered individual and small employer policies offered outside the exchange; such plan oversight would be outside of exchange operations, but under the aegis of state insurance commissioners.
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From page 117... ...
The exchanges and state insurance regulators will not be the only repositories of pertinent data; other state and federal sources might have to be mined to assess factors such as the size of the uninsured population, consumer satisfaction, health care utilization, quality of care, health status, and employer characteristics. In Recommendation 2a, the committee calls on the Secretary to establish a framework for data collection and research; this framework should be developed with advice from the National Benefits Advisory Council (Recom mendation 5 in Chapter 9)
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From page 118... ...
PROGRAM MONITORING AND RESEARCH The committee offers some guidance for the implementation of these recommendations in terms of data col lection via the exchanges and other sources, as well as some illustrative research questions. Learning from the Exchanges and State Regulators The EHB package will become a standard setter for the content of health insurance beyond the health exchange, but HHS can learn from those operating exchanges and from state regulators how the EHB are incorporated into health insurance products, what benefit design components are utilized to meet the coverage and premium require ments, how consumer preferences in the market (e.g., for high deductible plans)
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From page 119... ...
Items 5 and 6 will make clearer the landscape in benefit design, an important consideration in understanding trends in premium prices related to the EHB and measuring the impact of such benefit designs. Although the Secretary is not to preclude insurers from using various utilization manage ment techniques, there is a requirement in Section 1302 to ensure that coverage decisions, reimbursement rates, incentive programs, or designs of benefits are not discriminatory on the basis of age, disability, or expected length of life, while Section 1557 explicitly pertains to nondiscrimination based on race, national origin, and gender.
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From page 120... ...
Section 2719 of the Public Health Services Act, added by Section 10101(g) of the ACA, seeks to bring more consistency to what consumers can expect with respect to internal and external claims and appeals processes through new requirements for group health plans and health insurance companies.5 In particular, all subscriber contracts must have a final level of "external appeal" to an 4§ 1001, amending § 2715 of the Public Health Service Act [ 42 U.S.C.
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From page 121... ...
; more recent data presented to the IOM committee were not so proportionally disparate, showing 40 percent of medical necessity cases and 37 percent of experimental and investigational cases were overturned on independent external review (see Table 7-1)
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From page 122... ...
It is yet unclear the extent to which recent amendments to the interim final external review rules would present a barrier to accessing more detailed diagnostic and treatment code data for analysis of adverse benefit determinations; plans are only required to provide diagnostic and treatment code data for individual cases on request (HHS, 2011a,b; Jost, 2011)
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From page 123... ...
BROAD AREAS OF RESEARCH Here the committee mentions four broad areas of a comprehensive research agenda, recognizing that within each area a rich set of questions will arise. Understanding EHB definitions and their relationship to benefit design.
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From page 124... ...
Sources of data for addressing these questions include the standardized data on benefit content and design col lected from insurers and from state health insurance exchanges. Information on benefits and benefit design being offered by employers (e.g., DOL survey)
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From page 125... ...
, clinical information from electronic health records and other data sources of health care delivery systems, or data collected from surveys or qualitative interviews with patients selected for specific characteristics such as the presence of a chronic condition. Possible impact of EHB and benefit design decisions on the required elements for consideration.
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From page 126... ...
2011a. Interim final rules for group health plans and health insurance issuers relating to internal claims and appeals and external review processes under the Patient Protection and Affordable Care Act.
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From page 127... ...
2011. Group health plans and health insurance issuers: Rules relating to internal claims and appeals and external review processes; correction.
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