Health Insurance Reform Commission Overview
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Health Insurance
Reform Commission
OVERVIEW BY DIVISION OF LEGISLATIVE SERVICES
AUGUST 12, 2024
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Powers and duties of the Commission
Statutory background on mandated benefits
Assessment process for proposed mandated benefits
Essential Health Benefits Benchmark Plan process
Legislation referred during 2024 Session
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1.
Monitor federal and state implementation of the federal
Patient Protection and Affordable Care Act (ACA).
2.
Receive information provided by the Bureau of Insurance of
the State Corporation Commission (BOI) under § 30-343 and
assess the implications of the ACA’s implementation on
Virginia’s residents, businesses, and general fund.
3.
Consider the development of a comprehensive strategy for
implementing health reform in Virginia, including
recommendations for innovative health care solutions
independent of the approach embodied in the ACA.
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Receive reports from BOI pursuant to § 30-343 and recommend
health benefits to be included within the scope of the essential
health benefits (EHBs) provided under health insurance products
offered in Virginia, including any benefits not required by the ACA.
5.
Upon request of the Chair of the House Committee on Labor and
Commerce or Senate Committee on Commerce and Labor, assess
proposed mandated benefits and providers and recommend
whether such benefits or providers should be provided under
health care plans offered through or outside a health benefit
exchange.
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Conduct other studies of mandated benefits and provider
issues as requested by the General Assembly.
7.
Develop appropriate recommendations for legislative and
administrative consideration to increase access to health
insurance coverage, ensure that costs to purchasers are
reasonable, and encourage a robust market for health
insurance products in the Commonwealth.
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§ 1311(d)(3)(B) of the ACA
permits States to require a qualified
health plan in such State to offer benefits in addition to the essential
health benefits.
Defrayal requirement
: For any additional mandated benefit, the
State shall make payments (a) to an individual enrolled in such
qualified health plan or (b) to the qualified health plan on behalf of
such individual to defray the cost of such benefit.
Va. Code § 38.2-6506(A)(1)
provides that a plan cannot be certified
as a qualified health plan if the plan offers any state-mandated
benefit in addition to the essential health benefits.
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Any law imposed under Title 38.2 that becomes effective
on or after July 1, 2009, that provides for an insurance
mandate for policies of accident and health insurance shall
also apply to health coverage offered to state employees
pursuant to § 2.2-2818.
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Process governed by
§ 30-343
: Standing committees to request
Commission assessment.
Applies to proposals for “mandated health insurance benefits or
providers,” meaning health insurance coverage required by the
Commonwealth that is not mandated by federal law
and
:
Includes coverage for specific health care services or benefits;
Limits or restricts deductibles, coinsurance, copayments, or maximum
benefit amounts;
or
Includes a specific category of practitioners from whom an insured
may receive care.
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1.
Chair of House Labor and Commerce
or Senate Commerce and Labor
Committee requests the HIRC to
assess a proposed health insurance
mandate and sends a copy of such
request to BOI.
HIRC has 24 months to complete the
assessment.
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2.
Upon the BOI’s receipt of Chair’s request, the BOI shall prepare a
Step One analysis
pursuant to § 30-343(B) addressing:
I.
The extent to which the proposed mandate is currently
available under qualified health plans offered on the Virginia
Health Benefit Exchange
and
II.
Whether CMS has determined or would likely determine that
the proposed mandate exceeds the scope of the essential
health benefits according to the ACA.
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3.
BOI will present the results at a scheduled Commission meeting.
The presentation will provide background information and
address:
Whether the mandate likely exceeds the scope of the essential
health benefits;
Whether the mandate would likely lead to increased state costs; and
The extent to which the coverage proposed is already available.
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4.
HIRC shall determine whether the proposed mandate
shall be:
I.
Considered as part of an essential health benefits benchmark
plan review;
II.
Assessed jointly by the BOI and Joint Legislative Audit and
Review Commission (JLARC) in a Step Two analysis; or
III.
Considered in another manner by HIRC which may include no
further action.
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5.
BOI and JLARC will provide two separate but coordinated reports
and will present the results at a scheduled Commission meeting.
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BOI Assessment
:
Financial Impact of Proposed Mandate
•
Expected impact on:
•
Utilization of services and providers
•
Premium costs and administrative
costs of insurers
•
Total cost of health care in Virginia
•
Expected additional cost to state as
required by ACA
JLARC Assessment
: Current Status and
Need for Proposed Mandate
•
Background on proposed coverage and
medical condition
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Efficacy of proposed coverage
•
Current availability and utilization
•
Current financial impact on individuals
without proposed coverage
•
Consistency with purpose of insurance
•
Public health impact
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6. HIRC shall determine whether the proposed mandate
shall be:
I.
Recommended to the General Assembly;
II.
Considered as part of an essential health benefits benchmark
plan review; or
III.
Considered in another manner by HIRC which may include no
further action.
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The ACA requires states to select a set of essential health
benefits (EHB Benchmark Plan) for coverage in the individual
and small group markets
The EHB Benchmark Plan is updated via application to CMS
HB 2199/SB 1397 (2023) require HIRC and BOI to review the
EHB Benchmark Plan in 2025 and every five years thereafter
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After a Step One analysis is presented, HIRC may direct the
BOI to include a proposed mandate in the next EHB review.
Prior to any review year, the BOI will convene a stakeholder
workgroup to discuss and make recommendations regarding
any potential plan changes.
BOI will assess mandates referred by HIRC and estimate the
effects of including each benefit in the EHB Benchmark Plan.
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1.
BOI will submit findings and recommendations of the
workgroup and any assessments of proposed mandates to
HIRC by March 31 of the review year.
2.
HIRC shall hold at least two public hearings regarding
potential benefit changes by June 30 of the review year.
3.
By June 30 of the review year, HIRC will determine if any
application will be made to change the EHB Benchmark
Plan and identify any potential benefit changes for further
analysis.
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4.
BOI will conduct actuarial analysis of any benefit changes identified by
HIRC and present to HIRC by September 30 of the review year.
5.
If HIRC decides to submit an application for a new EHB Benchmark
Plan, HIRC shall hold at least two additional public hearings by
December 31 of the review year.
6.
By December 31 of the review year, HIRC shall determine which, if any,
potential benefit changes shall be included in a new benchmark plan
and shall make its recommendation to the General Assembly in the
form of a bill directing the BOI to select such new benchmark plan
accordingly at the next regular session of the General Assembly.
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Legislation Referred during 2024 Session
H.B. 230 (Simonds):
Health insurance; cost sharing for breast
examinations.
H.B. 513 (Hope):
State plan for medical assistance services and health
insurance; state plan for payment for PANDAS and PANS.
H.B. 604 (Price):
Health insurance; coverage for polycystic ovary
syndrome.
H.B. 610 (Price):
Health insurance; coverage for diabetes.
H.B. 760 (Delaney):
Health insurance; cost sharing payments for
insulin and diabetes equipment and supplies.
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Legislation Referred during 2024 Session
H.B. 935 (LeVere Bolling) / S.B. 118 (Locke):
Health insurance;
coverage for doula care services.
H.B. 946 (Lopez) / S.B. 376 (Boysko):
Health insurance; limit on cost-
sharing payments for prescription drugs under certain plans.
H.B. 1347 (Srinivasan):
Health insurance; coverage for polycystic
ovary syndrome.
S.B. 333 (Salim):
State plan for medical assistance services; fertility
preservation treatments; genetic material misuse; penalty.
S.B. 735 (Sturtevant):
Health insurance; denial of referral by direct
primary care provider prohibited.
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Health Insurance
Reform Commission
OVERVIEW BY DIVISION OF LEGISLATIVE SERVICES
AUGUST 12, 2024
This overview provides insights into the powers and duties of the Health Insurance Reform Commission, including monitoring the implementation of the Affordable Care Act, assessing mandated benefits, and developing strategies for health reform in Virginia. The commission aims to increase access to health insurance coverage and ensure reasonable costs for purchasers.
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Health Insurance Reform Commission OVERVIEW BY DIVISION OF LEGISLATIVE SERVICES AUGUST 12, 2024
Presentation Overview Presentation Overview Powers and duties of the Commission Statutory background on mandated benefits Assessment process for proposed mandated benefits Essential Health Benefits Benchmark Plan process Legislation referred during 2024 Session 2
Powers and Duties: Powers and Duties: 30 1. Monitor federal and state implementation of the federal Patient Protection and Affordable Care Act (ACA). 2. Receive information provided by the Bureau of Insurance of the State Corporation Commission (BOI) under 30-343 and assess the implications of the ACA s implementation on Virginia s residents, businesses, and general fund. 3. Consider the development of a comprehensive strategy for implementing health reform in Virginia, including recommendations for innovative health care solutions independent of the approach embodied in the ACA. 30- -342 342 3
Powers and Duties: Powers and Duties: 30 30- -342 342 4. Receive reports from BOI pursuant to 30-343 and recommend health benefits to be included within the scope of the essential health benefits (EHBs) provided under health insurance products offered in Virginia, including any benefits not required by the ACA. 5. Upon request of the Chair of the House Committee on Labor and Commerce or Senate Committee on Commerce and Labor, assess proposed mandated benefits and providers and recommend whether such benefits or providers should be provided under health care plans offered through or outside a health benefit exchange. 4
Powers and Duties: Powers and Duties: 30 30- -342 342 6. Conduct other studies of mandated benefits and provider issues as requested by the General Assembly. 7. Develop appropriate recommendations for legislative and administrative consideration to increase access to health insurance coverage, ensure that costs to purchasers are reasonable, and encourage a robust market for health insurance products in the Commonwealth. 5
Mandated Benefits: Statutory Background Statutory Background 1311(d)(3)(B) of the ACA permits States to require a qualified health plan in such State to offer benefits in addition to the essential health benefits. Defrayal requirement: For any additional mandated benefit, the State shall make payments (a) to an individual enrolled in such qualified health plan or (b) to the qualified health plan on behalf of such individual to defray the cost of such benefit. Va. Code 38.2-6506(A)(1) provides that a plan cannot be certified as a qualified health plan if the plan offers any state-mandated benefit in addition to the essential health benefits. 6
Mandated Benefits: Statutory Background Statutory Background Any law imposed under Title 38.2 that becomes effective on or after July 1, 2009, that provides for an insurance mandate for policies of accident and health insurance shall also apply to health coverage offered to state employees pursuant to 2.2-2818. 7
Assessment of Proposed Mandated Benefits: Overview Overview Process governed by 30-343: Standing committees to request Commission assessment. Applies to proposals for mandated health insurance benefits or providers, meaning health insurance coverage required by the Commonwealth that is not mandated by federal law and: Includes coverage for specific health care services or benefits; Limits or restricts deductibles, coinsurance, copayments, or maximum benefit amounts; or Includes a specific category of practitioners from whom an insured may receive care. 8
Assessment of Proposed Mandated Benefits: Assessment Request Assessment Request 1. Chair of House Labor and Commerce or Senate Commerce and Labor Committee requests the HIRC to assess a proposed health insurance mandate and sends a copy of such request to BOI. Chair of C&L or L&C HIRC BOI HIRC has 24 months to complete the assessment. 9
Assessment of Proposed Mandated Benefits: Step One Analysis Step One Analysis 2. Upon the BOI s receipt of Chair s request, the BOI shall prepare a Step One analysis pursuant to 30-343(B) addressing: I. The extent to which the proposed mandate is currently available under qualified health plans offered on the Virginia Health Benefit Exchange and II. Whether CMS has determined or would likely determine that the proposed mandate exceeds the scope of the essential health benefits according to the ACA. 10
Assessment of Proposed Mandated Benefits: Step One Analysis Step One Analysis 3. BOI will present the results at a scheduled Commission meeting. The presentation will provide background information and address: Whether the mandate likely exceeds the scope of the essential health benefits; Whether the mandate would likely lead to increased state costs; and The extent to which the coverage proposed is already available. 11
Assessment of Proposed Mandated Benefits: After Step One Analysis After Step One Analysis 4. HIRC shall determine whether the proposed mandate shall be: I. Considered as part of an essential health benefits benchmark plan review; II. Assessed jointly by the BOI and Joint Legislative Audit and Review Commission (JLARC) in a Step Two analysis; or III. Considered in another manner by HIRC which may include no further action. 12
Assessment of Proposed Mandated Benefits: Step Two Analysis Step Two Analysis 5. BOI and JLARC will provide two separate but coordinated reports and will present the results at a scheduled Commission meeting. BOI Assessment: Financial Impact of Proposed Mandate Expected impact on: Utilization of services and providers Premium costs and administrative costs of insurers Total cost of health care in Virginia Expected additional cost to state as required by ACA JLARC Assessment: Current Status and Need for Proposed Mandate Background on proposed coverage and medical condition Efficacy of proposed coverage Current availability and utilization Current financial impact on individuals without proposed coverage Consistency with purpose of insurance Public health impact 13
Assessment of Proposed Mandated Benefits: After Step Two Analysis After Step Two Analysis 6. HIRC shall determine whether the proposed mandate shall be: I. Recommended to the General Assembly; II. Considered as part of an essential health benefits benchmark plan review; or III. Considered in another manner by HIRC which may include no further action. 14
Essential Health Benefits Benchmark Plan: Overview Overview The ACA requires states to select a set of essential health benefits (EHB Benchmark Plan) for coverage in the individual and small group markets The EHB Benchmark Plan is updated via application to CMS HB 2199/SB 1397 (2023) require HIRC and BOI to review the EHB Benchmark Plan in 2025 and every five years thereafter 15
Essential Health Benefits Benchmark Plan: After Step One Analysis After Step One Analysis After a Step One analysis is presented, HIRC may direct the BOI to include a proposed mandate in the next EHB review. Prior to any review year, the BOI will convene a stakeholder workgroup to discuss and make recommendations regarding any potential plan changes. BOI will assess mandates referred by HIRC and estimate the effects of including each benefit in the EHB Benchmark Plan. 16
Essential Health Benefits Benchmark Plan: Review Process Review Process 1. BOI will submit findings and recommendations of the workgroup and any assessments of proposed mandates to HIRC by March 31 of the review year. 2. HIRC shall hold at least two public hearings regarding potential benefit changes by June 30 of the review year. 3. By June 30 of the review year, HIRC will determine if any application will be made to change the EHB Benchmark Plan and identify any potential benefit changes for further analysis. 17
Essential Health Benefits Benchmark Plan: Review Process Review Process 4. BOI will conduct actuarial analysis of any benefit changes identified by HIRC and present to HIRC by September 30 of the review year. 5. If HIRC decides to submit an application for a new EHB Benchmark Plan, HIRC shall hold at least two additional public hearings by December 31 of the review year. 6. By December 31 of the review year, HIRC shall determine which, if any, potential benefit changes shall be included in a new benchmark plan and shall make its recommendation to the General Assembly in the form of a bill directing the BOI to select such new benchmark plan accordingly at the next regular session of the General Assembly. 18
Legislation Referred during 2024 Session H.B. 230 (Simonds): Health insurance; cost sharing for breast examinations. H.B. 513 (Hope): State plan for medical assistance services and health insurance; state plan for payment for PANDAS and PANS. H.B. 604 (Price): Health insurance; coverage for polycystic ovary syndrome. H.B. 610 (Price): Health insurance; coverage for diabetes. H.B. 760 (Delaney): Health insurance; cost sharing payments for insulin and diabetes equipment and supplies. 19
Legislation Referred during 2024 Session H.B. 935 (LeVere Bolling) / S.B. 118 (Locke): Health insurance; coverage for doula care services. H.B. 946 (Lopez) / S.B. 376 (Boysko): Health insurance; limit on cost- sharing payments for prescription drugs under certain plans. H.B. 1347 (Srinivasan): Health insurance; coverage for polycystic ovary syndrome. S.B. 333 (Salim): State plan for medical assistance services; fertility preservation treatments; genetic material misuse; penalty. S.B. 735 (Sturtevant): Health insurance; denial of referral by direct primary care provider prohibited. 20
Health Insurance Reform Commission OVERVIEW BY DIVISION OF LEGISLATIVE SERVICES AUGUST 12, 2024
