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Essential Health Benefits: Balancing Affordability and Adequacy Kavita Patel MD, MS Engelberg Center for Health Care Reform The Brookings Institution February.

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Presentation on theme: "Essential Health Benefits: Balancing Affordability and Adequacy Kavita Patel MD, MS Engelberg Center for Health Care Reform The Brookings Institution February."— Presentation transcript:

1 Essential Health Benefits: Balancing Affordability and Adequacy Kavita Patel MD, MS Engelberg Center for Health Care Reform The Brookings Institution February 3, 2012 Washington, DC

2 Issues to Consideration Legislative Intent- set floor not ceiling? This is NOT benefit design (next slide) or benefit administration –Outstanding issues around cost containment strategies, alignment with delivery systems Governance/Administration –Medical necessity –Basis for evidence review, etc –Oversight and monitoring –Premium Issues 2

3 Various Benchmark Plans 3 Annual Deductible Copays for Office Visits Coinsurance for Hospital Coinsurance for Lab and X- RayPrescriptions Benchmark Plan Small Group Insurance Products in States Small Group Market $ $3020% Tiered copay for prescriptions ($10 for generic, $25 for brand- name drugs on the plans formulary, $50 for brand-name drugs not on the formulary) State Employee Health Benefit Plan (Colorado State Plan) $1,500$3020% Tiered copay for prescriptions ($10 for generic, $25 for brand- name drugs on the plans formulary, $50 for brand-name drugs not on the formulary) Federal Employee Health Benefit Plan $350$15 $100 plus 15% coinsurance 15% 15% coinsurance for generic prescription drugs, higher for non-generics Commercial Non- Medicaid HMO in State no deductible$20$250 No cost-sharing for lab or x-ray Three tiers of copayments for prescription drugs ($10 for generic, $25 for brand-name drugs on the plans formulary, $50 for brand-name drugs not on the formulary)

4 4 Implications for Various Stakeholders States –Variations in benefits and access to elements of care including behavioral health treatment, habilitative services, and routine pediatric oral/vision care –Legislative complications Insurers –Flexibility –Lack of uniform standard Patients and Families –Provide consumer feedback Policymakers –Oversight and guidance for exchanges –Appeals process

5 Opportunities for Various Stakeholders Researchers –Development of methods for comparative effectiveness research –Better understanding of rapid cycle evaluation and its role in modifying an EHB at a federal and state level Health Care Leaders –Act as the catalyst behind CMMIs pilots and evaluation efforts –Affordability State-Based Exchanges –Laboratories for initiatives –Increase consumer engagement 5

6 Thank you


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