Virginia Health Insurance Reform Commission: Essential Benefits Benchmark Plan Overview
The presentation highlights the Essential Health Benefits (EHB) Benchmark Plan review process, Virginia legislation requirements, and the creation of a new EHB Benchmark Plan for 2025. It covers changes in coverage, compliance with regulations, and the application process timeline leading to the effective date of the new plan in 2025.
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Presentation to Health Insurance Reform Commission Essential Health Benefits Benchmark Plan Julie Blauvelt Deputy Commissioner Bureau of Insurance April 18, 2023 Confidential
A review of the Essential Health Benefits requirement Virginia legislation related to this requirement EHB Benchmark Plan Application and Process Comments received on the 2025 EHB Benchmark Plan Draft Application The next EHB Benchmark Plan review process Presentation Overview Confidential
The ACA required states to set (or default to) a set of Essential Health Benefits that must be provided in every policy of individual or small group health insurance coverage. (The EHB Benchmark Plan) Section 38.2-3451 of the Code of Virginia Each state was required to choose (or default to) an EHB Benchmark Plan in 2014 and again in 2017. Virginia (through letter from then-Governor) chose what would have been the default EHB Benchmark Plan. HB 2198/SB 1399, which went into effect on March 22, 2023 requires BOI to select a new EHB Benchmark Plan for 2025. HB 2199/SB 1397 requires HIRC and BOI to review the EHB Benchmark Plan again in 2025 and every 5 years thereafter. Essential Health Benefits Benchmark Plan Confidential
Required by HB 2198/SB 1399 BOI created new EHB Benchmark Plan website at: https://scc.virginia.gov/pages/Essential-Health-Benefits- Benchmark-Plan Benefits document removing identifying company information BOI created generic document that focuses just on the benefits Changes to current EHB package: Expanded coverage for prosthetic devices and components Formula and enteral nutrition products as medicine Revised benefits to comply with: Updated federal and state requirements (i.e., MHPAEA, non-discrimination rules, new preventive care services) Mandated providers Revisions for 2025 EHB Benchmark Plan Confidential
2025 EHB Benchmark Plan Application Process 3/28/23: Draft 2025 EHB Benchmark Plan application posted on BOI website 3/29/23: BOI news release announcing public comment period 3/22/23: Governor signed HB2198/SB1399 4/12/23: Public comment period ends August 2023: CMS will make a determination on the application. 1/1/25: New EHB Benchmark Plan will be effective, if approved. 5/3/23: Final application due to CMS. Confidential
Public Comments Received Comments received this period: Virginia Poverty Law Center, Sara Cariano, Sr. Policy Analyst Encourage a transparent, data driven process with robust public input Comprehensive health data and claims data should determine the benefits to be considered Established process does not allow for quick action to address health emergencies Suggest that the workgroup be independent and comprised of health and data experts and patient advocates Suggested data the workgroup should review and that the workgroup may recommend benefits that did not go through the legislative and HIRC process Concerned citizen Objected to defining formula as medicine and government control in general Will be provided to HIRC in BOI report due March 31 of each review year. Confidential
HIRC Review Process for Proposed Mandated Benefit or Provider (Section 30-343) Chair of House Commerce & Energy or Senate Commerce & Labor sends letter to HIRC (copy to BOI) requesting assessment of proposed mandate. BOI prepares a Step 1 analysis upon receipt of request received from the Committee Chairs. HIRC determines if the proposed mandate shall be: (i) Part of EHB review (ii) Assessed through Step 2 analysis; or Does the proposal exceed the scope of EHB? (iii) other. Confidential
In 2024, BOI will convene a workgroup to discuss and make recommendations for potential changes to the EHB Benchmark Plan. BOI will assess any mandates that have been referred by HIRC for EHB consideration and estimate effects of including the benefit in the Benchmark Plan. By March 31, 2025, BOI will report to HIRC on the findings and recommendations of workgroup and assessments of referred mandates. HIRC will need to conduct two public hearings before June 30, 2025 to solicit feedback on potential changes to the EHB Benchmark Plan. By June 30, 2025, HIRC will determine if Virginia will seek changes to the EHB Benchmark Plan, and identify potential benefit changes for BOI to analyze for inclusion in the revised EHB Benchmark plan. If HIRC decides to submit an application for a new EHB Benchmark Plan, HIRC must hold two additional public hearings prior to December 31, 2025. By September 30, 2025, BOI will conduct an actuarial analysis of potential new EHBs proposed by HIRC. By December 31, 2025, HIRC will determine the changes, if any, that will be recommended by legislation for inclusion in the 2028 EHB Benchmark Plan application. Next EHB Benchmark Plan Review and Potential Update (Section 30-343.1) Confidential
BOI will finalize and submit the 2025 EHB Benchmark Plan Application to CMS for review. Virginia should receive a determination on the 2025 EHB Benchmark Plan Application by Summer 2023. HIRC will operate under a new process for reviewing proposed mandates (additional options for proposed mandates). During 2024, BOI will assemble a workgroup to provide recommendations as well as a summary of benefits HIRC has assessed for the March 31, 2025 report regarding a potential 2028 updated EHB Benchmark Plan. In Summary Confidential
Questions? Confidential
