PacificSource Chosen by Workgroup for Essential Health Benefits Package

Now Governor John Kitzhaber must either accept the recommendation or choose a different health plan by September 30

June 25, 2012— A 19-member, governor-appointed workgroup made up largely of hospital and insurance representatives has selected PacificSource’s small group plan as the state’s essential health benefits package.

Governor Kitzhaber must either accept the recommendation, or ask that a different plan be chosen by September 30. Otherwise, the federal government will make that decision.

PacificSource’s small group plan currently provides coverage to 28,819 people, making it the state’s third largest small group plan. If Kitzhaber accepts the workgroup’s recommendation, the plan’s benefits will be the basic foundation for all individual and small group insurance plans
offered in the state. It will also be the state health insurance exchange’s bronze plan starting in January 2014.

The Affordable Care Act requires each state to offer an “essential health benefits package” to individuals and small businesses.

The essential health benefits package must include services from 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and infant care; prescription drugs; mental health and substance abuse services; laboratory services; preventive services; rehabilitation and habilitation services, and pediatric services.

Whether a plan included all 10 categories was not the sole deciding factor by the workgroup which recommended PacificSource, said Anthony Behrens, a senior policy analyst with the Oregon Insurance Division.

“That was made irrelevant by the guidance the feds provided,” he said. “All of the 10 plans [considered] met most of those categories.”

The workgroup considered whether the PacificSource plan would increase costs in the individual market and lead to disruption if insurance companies had to drastically change their individual and small group plans.

The PacificSource plan does not include benefits from all 10 categories, meaning it will have to be supplemented with additional benefits. For example, it does not offer habilitation services, which help individuals learn new skills or functions, such as providing speech therapy to a child who has not learned how to talk.

No plans in Oregon offer such benefits, Behrens, and state officials are awaiting word from the federal government about its expectations in the benefit structure.

PacificSource’s plan also doesn’t include pediatric dental and vision care, which Behrens said is fairly typical, and those benefits could be offered through the Children Health Insurance Program or the Federal Employees Dental and Vision Insurance Program (FEDVIP).

The purpose of an essential health benefits package is consumer-driven: the package ensures that every insurance plan offered to individuals and the small group markets includes a basic level of coverage.

“[A consumer] is guaranteed that they’re going to get a product that meets certain standards,” Behrens said.

Last December, the federal Health and Human Services department announced it would allow states to determine their essential health benefits package and were told they could either choose from among the three largest small group plans by enrollment, any of the three largest federal employee health plan options or the largest insured commercial non-Medicaid HMO plan.

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