Consumer Advocates Keep Careful Eye on Essential Health Benefit Workgroup

Determining the state’s benchmark plan for an essential health benefit package is a “narrow” decision to make, but will have major ramifications for Oregon consumers

April 25, 2012—The stakes are high for choosing an insurance plan that will define Oregon’s essential health benefits package, even though the question the recent Governor-appointed essential health benefit workgroup will answer is a wonky one—especially considering that the workgroup will get into the nitty gritty details of comparing insurance plans.

The workgroup expects to make a recommendation to Governor Kitzhaber by September that defines the benchmark plan for the state’s essential benefits package, which will ultimately become the bronze plan offered by Oregon’s health insurance exchange.

To become the benchmark plan, the workgroup must choose one of the following:

  • Any of the three largest small group plans in Oregon’s small group market, by enrollment; any of the three largest state employee health plans by enrollment; any of the three largest federal employee health plan options by enrollment, or the largest insured commercial non-Medicaid HMO plan in Oregon.

Basically, an “essential health benefits package” includes ten categories of health services and benefits insurers must offer in the exchange:

  • Ambulatory patient services;
  • Emergency services;
  • Hospitalization;
  • Maternity and infant care;
  • Prescription drugs;
  • Mental health and substance abuse services;
  • Laboratory services;
  • Preventive services;
  • Rehabilitation services, and
  • Pediatric services.

Oregon can choose which services belong in its benchmark plan, following a decision last December by the U.S. Department of Health and Human Services giving states that authority.

Liz Baxter, executive director of We Can Do Better who chairs the exchange board, called the workgroup’s charge to determine the benchmark plan “a fairly narrow question.”

Besides the benchmark plan, consumers and small businesses can choose a silver, gold or platinum plan with different cost sharing requirements.

For example, under a bronze plan, people could pay up to 40 percent for deductibles, co-payments and co-insurance, compared to 30 percent for a silver plan, 20 percent for the gold level and 10 percent for a platinum plan. Those details have not yet been worked out.

“A lot of dominoes are at play,” said Baxter, who hopes the plans will be distinct enough, in terms of the benefits they offer, so that people can make a “meaningful” choice.

“We’re all different. Different ages, different circumstances,” she said. “It’s important to make sure that the right things are covered in the right way at the right time.”

In January 2014, the exchange is expected to offer affordable health coverage to as many as 750,000 uninsured Oregonians. Under the Patient Protection and Affordable Care Act, health plans must include the essential health benefits packack, regardless of whether they are offered inside or outside of the exchange.

When the workgroup got under way, consumer advocates were concerned about its composition and transparency since 12 of its 19 members either work for insurance companies or hospitals. One person represents a mental health organization, two represent dentistry, and only two people are employed by non-profit organizations.

But those concerns have been abated, given the workgroup’s charge to choose a benchmark plan which requires technical and deep knowledge of insurance plans.

“You have to have the insurance industry together” to get that information, said Felisa Hagins, political director of the Service Employees International Union (SEIU) Local 49.

There were also concerns about transparency since it had been thought the workgroup wouldn’t hold public meetings. But the meetings are public, and the workgroup is also expected to hold a public comment period where people can share their opinions.


Visit the Essential Health Benefit Workgroup’s website here.

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