Free Daily Headlines :

  • COVID-19
  • Vaccine Info
  • Money
  • Politics
  • Education
  • Health
  • Justice
  • More
    • Environment
    • Economic Development
    • Gaming
    • Investigations
    • Social Services
    • TRANSPORTATION
  • Opinion
    • CT Viewpoints
    • CT Artpoints
DONATE
Reflecting Connecticut’s Reality.
    COVID-19
    Vaccine Info
    Money
    Politics
    Education
    Health
    Justice
    More
    Environment
    Economic Development
    Gaming
    Investigations
    Social Services
    TRANSPORTATION
    Opinion
    CT Viewpoints
    CT Artpoints

LET�S GET SOCIAL

Show your love for great stories and out standing journalism

State benefit mandates could cost the state under health reform

  • by Arielle Levin Becker
  • November 18, 2011
  • View as "Clean Read" "Exit Clean Read"

Expanding the list of services that health insurance plans must cover has become a perennial fight in the state legislature. Connecticut now has more health benefit mandates than nearly all other states, a consultant told a state board Thursday. And when federal health reform rolls out in just over two years, that could leave the state, not the insurers, with a bill to pay.

Under the reform law, thousands–possibly hundreds of thousands–of individuals and small businesses will buy their health care coverage through the state’s health insurance exchange, a marketplace for purchasing health plans. Every plan sold on the exchange must cover a set of federally required benefits, known as “essential health benefits.”

States can require health plans sold on the exchange to cover additional benefits. But if they do, the state must pick up the cost of covering them.

Although it’s not yet clear what the benefits federal government will require, as many as three-quarters of the benefits that Connecticut mandates could exceed what the federal government requires, according to a presentation by a consultant to the board that oversees the exchange Thursday.

“These state mandates can really provide significant patient protections,” Kevin Lurito, a principal at the firm Mercer, told the board. “However, states will now have to assume the costs associated with these requirements.”

And that could add up. State benefit mandates in 2009 accounted for about 22 percent of premium costs for group insurance coverage and about 18 percent of premiums for individual coverage, according to a report by researchers at the University of Connecticut Center for Public Health and Health Policy. Those include mandates to cover cancer, tumors and leukemia–the costliest benefit–as well as some cancer screenings and autism spectrum disorder therapies.

The health reform law outlines 10 categories of benefits that must be covered by plans sold on the exchange, including prescription drugs and emergency hospitalization. But the U.S. Department of Health and Human Services has discretion to require expansive coverage or limited benefits within each category.

HHS hasn’t yet said what benefits it will consider essential. But a clue to the direction it will take came from the Institute of Medicine, which issued recommendations at the department’s request for how to determine the essential benefits.

Its suggestions: The package should be based on what small employers offer. Affordability and sustainability must be key factors. And the package should be designed to fit a predetermined price, not created independent of cost considerations.

“Without some constraint on the size of the [essential health benefits] package, the premium prices faced by individuals seeking to obtain coverage both inside and outside of the exchanges in the individual and small business market may prove unaffordable to the target population and diminish access to health insurance coverage,” the institute said in its report.

Mercer’s analysis found that nine of Connecticut’s mandated benefits would clearly fall under the federal essential benefits requirements. Those include coverage of newborn infants, diabetes testing and treatment, prostate and colorectal cancer screening, mammography and breast ultrasounds, prescription contraceptives, and the cancer, tumors and leukemia benefit.

Altogether, they account for 9.1 percent of claims costs in the individual market, and 10.6 percent of claims costs in the small group market.

For the rest of the state’s mandated benefits–28 that apply to the individual market and 31 that apply to small group health plans–it’s uncertain whether they will be considered essential, Lurito said. Those include coverage of mental or nervous conditions, off-label use of cancer drugs, infertility diagnosis and treatment, and a requirement that health plans cover the most effective psychotropic drugs.

It’s possible that some of those state mandates will be covered, but Lurito noted that the federal government might not require the services to be covered at the same level the state does.

So how should the state deal with a potential disparity between its mandates and the federally required benefits in exchange plans?

Lurito laid out some options: Wait for further guidance from HHS and then re-evaluate. Maintain all existing mandates–which would require the state to pay a portion of the premium costs of plans sold on the exchange. Or review and modify some mandates based on economic, social and medical efficacy.

As an example, he cited coverage of Lyme disease treatment, which the state mandates. The state requirement exceeds recommended treatment therapies, he said, which could make it unlikely that the federal government would include it in its list of essential benefits.

But, Lurito added, Connecticut has a much higher prevalence of Lyme disease than the country as a whole, and the estimated costs of the benefit is negligible when spread across the insured population. When the state considers its approach to mandates that don’t match the federal requirements, he said, it will need to look both at costs and social impact.

State Healthcare Advocate Victoria Veltri said it’s important that any evaluation of the state’s benefit mandates takes a broad view of costs and benefits. Coverage of hearing aids for children or ostomy supplies could have a significant effect on days missed from work or school, or reduce medical visits, she said.

“It really needs to be a cost-benefit analysis done, not just a cost analysis,” she said.

Veltri said she was a bit nervous about the idea of building a plan to hit a cost goal, rather than to offer certain benefits, based on the state’s experience developing the Charter Oak Health Plan. Its premiums were set at $250 a month, and despite efforts to design a suitable plan at that price, it ended up being bare bones, she said. Premiums have since gone up to $446 a month because it wasn’t possible to maintain the lower price and quality coverage, she said.

Mickey Herbert, an exchange board member and former CEO of the insurer ConnectiCare, said the mandates are a critical piece to address because affordability is key to the insurance plans sold under health reform. If the state’s costs for its mandates are high enough, the legislature might be compelled to repeal some of them, he said.

“Perhaps,” replied Benjamin Barnes, the state budget director.

Instead of focusing on the costs of mandates, more attention should go to eliminating other cost drivers that raise the cost of premiums while adding no value to the health care system, said Mary Fox, another board member.

It’s also important that the required benefits include prevention and wellness measures that can prevent disease from progressing and address problems like obesity, making sure that plan designs support the right interventions, said Fox, a former senior vice president for Aetna Product Group.

The presentation was part of a larger analysis by Mercer aimed at helping the exchange board as it develops the exchange. Mercer is expected to provide information about other parts of its research at later meetings.

Sign up for CT Mirror's free daily news summary.

Free to Read. Not Free to Produce.

The Connecticut Mirror is a nonprofit newsroom. 90% of our revenue comes from people like you. If you value our reporting please consider making a donation. You'll enjoy reading CT Mirror even more knowing you helped make it happen.

YES, I'LL DONATE TODAY

ABOUT THE AUTHOR

Arielle Levin Becker

SEE WHAT READERS SAID

RELATED STORIES
Advocates call on state to improve response to vulnerable students
by Adria Watson

State child advocate Sarah Eagan and attorney Martha Stone want the state to do more for these students during COVID.

CT budget leaders want to use massive savings to expand COVID-19 relief
by Keith M. Phaneuf

Gov. Ned Lamont’s administration expects to spend about $630 million less than legislators authorized.

The game is changing. Chris Murphy says he’s ready to play.
by Mark Pazniokas

The question for Sen. Chris Murphy no longer is where might he go next, but what can he do now.

Connecticut’s $100 million college shell game
by Stephen Adair

The plan to consolidate the 12 community colleges in Connecticut into one college with 12 campuses is called “Students First,” which is ironic because it does not fund students first.  It funds a new administration in a new, statewide bureaucracy. The Board of Regents (BOR) and the Connecticut State Colleges and Universities (CSCU) system office […]

Inconsistent television captioning is a barrier to equal access
by Jeffrey Bravin and Barbara Cassin

Our world long ago entered the age of the 24-hour news cycle, and a full understanding of the “who, what, when, where and why” of the news is critical for deaf, deafblind and hard of hearing citizens. Yet, Connecticut’s inconsistent quality of television captioning locks our community out of the complete sense of what is happening.

Support Our Work

Show your love for great stories and outstanding journalism.

$
Select One
  • Monthly
  • Yearly
  • Once
Artpoint painter
CT ViewpointsCT Artpoints
Opinion Connecticut’s $100 million college shell game
by Stephen Adair

The plan to consolidate the 12 community colleges in Connecticut into one college with 12 campuses is called “Students First,” which is ironic because it does not fund students first.  It funds a new administration in a new, statewide bureaucracy. The Board of Regents (BOR) and the Connecticut State Colleges and Universities (CSCU) system office […]

Opinion Inconsistent television captioning is a barrier to equal access
by Jeffrey Bravin and Barbara Cassin

Our world long ago entered the age of the 24-hour news cycle, and a full understanding of the “who, what, when, where and why” of the news is critical for deaf, deafblind and hard of hearing citizens. Yet, Connecticut’s inconsistent quality of television captioning locks our community out of the complete sense of what is happening.

Opinion A just stimulus package is a start toward true racial inclusion
by Carlton L Highsmith

For centuries Blacks have been denied full participation in the American Dream. But for the sake of our collective progress, as we recover from the crippling economic effects of COVID-19, our country has a mandate to acknowledge its history of systematic institutionalized exclusionary practices and not repeat them.

Opinion Hamden taxpayers are left in the dark
by Lauren Garrett

“A budget is a moral document.” This phrase is often heard during budget season from both sides of the aisle advocating for their personal values. The municipal operating budget is the cost of running a town which includes paying for employees, schools, and other services. Asking residents to pay property taxes requires a public trust.

Artwork Grand guidance
by Anne:Gogh

In a world of systemic oppression aimed towards those of darker skintones – representation matters. We are more than our equity elusive environments, more than numbers in a prison and much more than victims of societal dispositions. This piece depicts a melanated young man draped in a cape ascending high above multiple forms of oppression. […]

Artwork Shea
by Anthony Valentine

Shea is a story about race and social inequalities that plague America. It is a narrative that prompts the question, “Do you know what it’s like to wake up in new skin?”

Artwork The Declaration of Human Rights
by Andres Chaparro

Through my artwork I strive to create an example of ideas that reflect my desire to raise social consciousness, and cultural awareness. Jazz music is the catalyst to all my work, and plays a major influence in each piece of work.”

Artwork ‘A thing of beauty. Destroy it forever’
by Richard DiCarlo | Derby

During times like these it’s often fun to revisit something familiar and approach things with a different slant. I have been taking some Pop culture and Art masterpieces and applying the vintage 1960’s and 70’s classic figures (Fisher Price, little people) to the make an amusing pieces. Here is my homage to Fisher -Price, Yellow […]

Twitter Feed
A Twitter List by CTMirror

Engage

  • Reflections Tickets & Sponsorships
  • Events
  • Donate
  • Newsletter Sign-Up
  • Submit to Viewpoints
  • Submit to ArtPoints
  • Economic Indicator Dashboard
  • Speaking Engagements
  • Commenting Guidelines
  • Legal Notices
  • Contact Us

About

  • About CT Mirror
  • Announcements
  • Board
  • Staff
  • Sponsors and Funders
  • Donors
  • Friends of CT Mirror
  • History
  • Financial
  • Policies
  • Strategic Plan

Opportunity

  • Advertising and Sponsorship
  • Speaking Engagements
  • Use of Photography
  • Work for Us

Go Deeper

  • Steady Habits Podcast
  • Economic Indicator Dashboard
  • Five Things

The Connecticut News Project, Inc. 1049 Asylum Avenue, Hartford, CT 06105. Phone: 860-218-6380

© Copyright 2021, The Connecticut News Project. All Rights Reserved. Website by Web Publisher PRO