November 30, 2012

November 30 Washington Update

Greetings from Washington!  We hope everyone had a peaceful and plentiful Thanksgiving.  This update will focus on the funding of Family-to-Family Health Information Centers (F2Fs) and some significant proposed regulations to implement the Affordable Care Act (ACA), including a proposed rule about "Essential Health Benefits."

F2F Funding.  Good news!  There is a new cosponsor of the House F2F funding bill - Rep. Peter Welch (D-VT)

At this point, we are suggesting that constituents contact only targeted Members of Congress to ask them to support the funding legislation (and thank those who have already cosponsored the bill).  We will let you know if you are represented by one of the key lawmakers who still needs to be approached.  As discussed earlier, we are hoping to get the F2F funding extension incorporated into a viable piece of legislation.  Candidates for such a legislative "vehicle" include the "doc fix," to prevent a reduction in Medicare reimbursement to physicians, and legislation to implement any sort of budget deal that is reached in the coming weeks or months.

Lawmakers are anxious to avoid tax increases and spending cuts that will automatically kick in after the new year if they fail to act.  While it is unclear how a deal will be struck to do this, it is fairly safe to say that it will happen at the last minute - probably not much before Christmas Eve, if then. 

ACA implementation 

Essential Health Benefits.  As explained in earlier updates, the ACA requires that all new, non-grandfathered plans in the individual and small group markets, both inside and outside the Exchanges, offer a standard package of benefits known as "Essential Health Benefits" (EHB).  The ACA listed 10 categories of benefits that must be included in the EHB package. Of particular interest to CYSHCN, these benefit categories include "mental health and substance use disorder services, including behavioral health treatment," "rehabilitative and habilitative services and devices," and "pediatric services, including oral and vision care."


Last December, HHS indicated in an informal "bulletin" that it would allow states to determine the scope of benefits that will be offered in each category based on one of several types of "benchmark" plans from which a state could choose:  (1) the largest plan by enrollment in any of the three largest small group insurance products in the State's small group market; (2) any of the largest three State employee health benefit plans by enrollment; (3) any of the largest three national FEHBP (federal employee) plan options by enrollment; or (4) the largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the State.

Last week, HHS issued a formal proposed rule to govern states' creation of their EHB packages.  One of its significant features is that, at least temporarily, states will have the authority to define the "habilitation" benefit if the chosen benchmark plan does not cover such services (e.g., OT, PT, speech therapy for people to acquire or retain these skills).  If a state does not do so, then the insurer has flexibility about what habilitation benefits to cover. (See Proposed Rule §156.110(f) and §156.115.) 

Comments on the proposed rule, which also sets forth cost-sharing regulations, are due on December 26.  A summary of the proposed rule can be found here.  To aid in its assessment, HHS has provided detailed information on the proposed EHB-benchmark plans for each of the 50 states and the District of Columbia, along with a Guide to Reviewing the State Benchmarks.  The blog of the Georgetown Center for Children and Families discusses how the proposed rule might affect children and families.

Family Voices will be working to develop comments and to provide assistance for SAOs to do so as well. 

Market reforms.  On November 20 the administration also issued a proposed rule regarding implementation of the market reforms mandated by the Affordable Care Act (ACA), such as the rules regarding variations in premiums and the ban on pre-existing condition exclusions, which generally take effect in 2014 for insurance sold in the individual or small group markets.  The rule clarifies that premium variations must not be based on any factors (such as health status) other than those specified on the law -- age, tobacco use (under certain circumstances), family size, and geographic location.  The proposed rule is rather technical, but HHS has prepared a summary and slide show that explain it.  Public comments are due on December 26.

Navigators.  Today, the administration issued an update on the progress of the establishment of state insurance Exchanges and the Federally Facilitated Exchange (FFE) that will be available in states that choose not to establish their own Exchanges.  Of note:  HHS (CMS) will fund a Navigator grant program in FFE states "to provide consumers with fair, unbiased help in selecting and applying for health coverage and determining if they are eligible for tax credits.  These Navigator grants will be awarded in June 2013.  Navigator grants will also be awarded by state-run Exchanges.  Entities such as F2Fs will be eligible to receive Navigator grants, so should be on the lookout for both federal and state-issued Navigator standards and application processes.  (We hope to provide more information on this topic in the future.)

As always, please feel free to contact us with any questions. 

Brooke Lehmann, MSW, Esq.


Janis Guerney, Esq.


NOTE:  Past issues of the Washington update can be found on the Family Voices home page by scrolling down in the "News Feed" section.