Health exchange panel struggles to balance need vs. cost in ‘benchmark’ plan

The panel working to create the state’s first health exchange received a crucial recommendation Wednesday: Don’t make the insurance plans so affordable that they don’t cover essential patient needs.

A working group of the exchange’s board of directors recommended unanimously Wednesday that it establish a health benefits “benchmark” — the minimum levels of coverage plans in the exchange must provide — based on ConnectiCare’s HMO plan.

In doing so, the Health Plan Benefits and Qualifications Advisory Committee opted against the Aetna qualified point-of-service plan after several members argued it offered too little coverage in key areas.

“What we’re seeing here is not getting it done,” said Dr. Joseph Treadwell, the Connecticut Podiatric Medical Association’s representative to the working group. Treadwell particularly objected to a portion of the Aetna plan that allowed a maximum of 20 outpatient physical therapy visits per year.

In certain cases where limbs have been amputated, he said, that limit would be particularly insufficient.

“People need months and months of physical therapy to recover from some of these” conditions, added Dr. Robert McLean of the Connecticut State Medical Society. “We should err on the side of caution and make sure the essential benefits package is adequate for people’s needs.”

Besides 40 outpatient rehabilitation services per year, some of the other coverage standards in the ConnectiCare plan recommended Wednesday include:


  • 90 days of skilled nursing services and inpatient rehabilitation services per year;
  • 20 chiropractic visits per year;
  • Durable medical equipment;
  • Comprehensive services for autism patients.


One of the co-chairs of the working group, Department of Insurance Deputy Commissioner Anne Melissa Dowling, urged members to remember to balance patient needs with affordability.

An exchange is a set of state-regulated health plans from which individuals and small businesses can buy coverage with the help of federal subsidies. All states must have exchanges operational and federally certified by Jan. 1, 2014, under the national health care reform legislation enacted two years ago.

As many as 200,000 uninsured residents in Connecticut potentially are eligible to buy subsidized insurance through the exchange. And the “benchmark” standards the state adopts also would apply, according to federal health care reform, to private insurance plans sold outside of the exchange to individuals and small businesses.

Uninsured people who buy coverage through the exchange starting in 2014 is expected to include many patients with “pent up health problems” that prevented them from finding affordable coverage in the past, Dowling said.

And if the state sets the benchmark too high, the result could be a huge jump in the premiums, deductibles and other charges that insurance companies would charge.

“We want to make sure we don’t do something that feels good, but that nobody can afford,” Dowling said.

The working group’s recommendation now heads to the health exchange’s board of directors, which is expected to review the matter at its July 26 meeting.

The final decision on benchmark standards rests with Gov. Dannel P. Malloy’s administration.

The working group also reviewed two plans provided by Anthem Blue Cross Blue Shield — including the plan commonly offered to Connecticut state employees — but didn’t recommend either as the health exchange benchmark, arguing the more extensive level of coverage might prove too expensive.