SustiNet Board of DirectorsSeptember 8, 2010Anya Rader WallackKatharine LondonLinda GreenAndrew Cohen

Recap of July meeting

• Discussion of what it means to be in SustiNet

• Discussion of what populations should have access to SustiNet

• Board asked to see a range of options

• Particular interest in municipal and non-profit employees

• Cost estimates from Dorn and Gruber, revisions to come

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Topics for today

• Covered services in SustiNet: What services currently are covered for “core”

populations? What improvements could be made, particularly with

respect to prevention and wellness? For additional populations, what principles should guide

the choice of covered benefits?• Public health investments to complement SustiNet:

What should the board recommend to the legislature? What are the highest priorities?

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Part ICovered services in SustiNet

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The “original policy proposal” on covered services

• Comprehensive benefits, consistent with SustiNet law

• Multiple benefit options, with differing levels of benefits and cost-sharing and varying degrees of network flexibility

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SustiNet law: covered services• Law lists 15+ categories of services

• Coverage is broad and includes preventive and acute medical care, prescription medications, home health, vision, family planning, podiatry, behavioral health and dental, tobacco cessation, obesity counseling

• Subject to state mandates

• No copayments for preventive care

• Behavioral health parity

• Dental coverage comparable to median offered by lg. employers in northeast

• Any change in state employee benefits subject to collective bargaining

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SustiNet law: covered services (continued)

• Office of Healthcare Advocate develops model benefit packages

• Any benefits offered to employer groups must be as comprehensive as the model benefit packages

• The board can modify the standard benefits package if changes are cost-effective

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Federal health reform: covered services and benefit design

• No lifetime or annual limits

• Required “essential benefits” are defined by the Secretary of HHS

• Must be like a “typical employer plan”

• Plans in small group and non-group must offer plans that are 60, 70, 80 and 90 percent of actuarial value of essential benefits

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Federal reform: covered services and benefit design (continued)

• Limits on out-of-pocket expenses

• Lower out-of-pocket limits for low-income

• New Medicaid eligible population: essential benefits, plus drugs and mental health (could be different from current CT Medicaid)

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Federal reform: preventive services

• Plans must cover preventive services recommended by the US Preventive Services Task Force

• Medicare will cover an annual wellness visit providing a personal prevention plan

• No cost sharing for prevention in all plans• Grants to state for healthy lifestyle incentives

in Medicaid

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Guidance on covered services from your task forces and advisory committees

• All “A” or “B” rated items on the US Preventive Services Task Force list addressing physiological, emotional, mental, and developmental conditions for members of all ages

• Annual Individual Preventive Care Plan, like Medicare• Behavioral health services and screenings• Dental services• Tobacco Cessation, including counseling, nicotine replacement products and

prescription medications• Nutritional counseling to support weight management • Support for breast feeding moms• Educational programs for families to build healthier lifestyles• Chronic care management programs

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Current state employee and Medicaid benefits

• Similar in breadth to SustiNet offerings

• Do not cover tobacco cessation, nutritional counseling or wellness programs

• Low or no cost sharing for preventive services

• Benefits subject to collective bargaining

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Comparison of covered services

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  Selected Covered Services in Sustinet PlansMA Commonwealth

Care Covered Services

  Sustinet

Act Husky A and Medicaid LIA

Husky

B

Charter Oak Plan

State Employees & Retirees

(in-network care)

Municipal Employee HIP

Under 100% FPL

200%-300% FPL

Preventive Care $ $ $Outpatient Physician Visits

$ $ $ $ $ $

Lab and Diagnostic X-Ray

# $

Inpatient Hospital # $Emergency Department without Inpatient Admission

$ $ $ $

Rehabilitation $ $ $

Home Health $

Prescription Drugs $ $ $ $ $ $Behavioral Health Inpatient

$ $ $

Behavioral Health Outpatient

$ $ $ $

Substance Abuse Inpatient

$ $ $

Substance Abuse Outpatient

$ $ $ $

Dental Services # $

Eye Exams $ $ $ $Tobacco Cessation

Nutritional Counseling for Obesity

Wellness Programs

Covered Service

$

Covered Service with a copay

#

Covered Service with co-insurance and often deductibles

Not covered

KEY:

Additional benefits and services that affect health status

Early evaluation and diagnosis• Health needs assessments• Evidence-based screenings• Identification of developmental delays• Consumer choice

Support for lifestyle modifications• Smoking cessation• Substance abuse cessation• Nutritional counseling and weight loss coaching• Stress management

Chronic conditions• Improving medication compliance

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Key points regarding covered services

• Consumer engagement in managing health is central to improvement – can be influenced through covered services and cost sharing

• Covered services and benefit design also can influence care coordination

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Part IIPreventive services and public

health investments

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The “original policy proposal” on public health investments

• Obesity prevention• Tobacco cessation• Immunizations, screenings at work, school,

community• Primary care workforce

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Federal health reform: prevention and public health investments

• Prevention and public health investment board with dedicated, stable funding for prevention, wellness and public health activities

• National prevention and health promotion outreach and education campaign

• Grants for school-based health centers• Oral health prevention• Nutrition labeling at chain restaurants• Pilot program for health risk assessments at CHCs

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Guidance on public health investments from your task forces and advisory committees

• Conduct statewide surveillance of key health indicators, using standard national surveys

• Provide more tobacco cessation services, including telephone Quitline, counseling, nicotine reduction products

• Include in K-12 education: tobacco, drug and alcohol use prevention, nutrition, stress management, exercise

• Improve the nutrition environment in schools and day care facilities & reduce unhealthy marketing to kids

• Conduct a public education campaign to describe the Patient-Centered Medical Home model & its benefits

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Part IIIDecision points

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Central issues/decision points: covered services

• For additional populations, what principles should guide the choice of covered services?

• Very little can be left out due to state mandates, SustiNet language and the “commercial mainstream” requirement

• Is anything missing? 

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Potential principles

• Comprehensive benefits• Consistent with “mainstream” of commercial

marketplace• Emphasis on prevention• Integrated medical-behavioral health• Flexibility to change over time based on outcomes

studies of larger populations• Supportive of Patient-Centered Medical Home Model,

with emphasis on prevention, care coordination and chronic care management

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Central issues/decision points: public health investments

• What principles should guide the Board in choosing to recommend state public health investments?• Investments that cannot be made by a health plan?

• Investments that can be made more efficiently by state government?

• Investments with a long-term return on investment (ROI)?

• Investments that require a statutory or regulatory change?

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Work plan for the next three months

• September: delivery system• October: administration and governance

(includes presentation on implications of licensure for SustiNet)

• November: costs and financing (includes implications of pursuing the federal Basic Health Program option)

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Appendix:Minimum Covered Services in

MassachusettsMassachusetts “Minimum Credible Coverage” sets standard for covered services for plans that meet the state’s individual mandate. Services include:

•Ambulatory patient services, including outpatient, day surgery and related anesthesia •Diagnostic imaging and screening procedures, including x-rays •Emergency services •Hospitalization (including at a minimum, inpatient acute care services which are generally provided by an acute care hospital for covered benefits in accordance with the member’s subscriber certificate or plan description) • Maternity and newborn care •Medical/surgical care, including preventive and primary care •Mental health and substance abuse services •Prescription drugs •Radiation therapy and chemotherapy

Sustinet Law is less specific on some aspects such as radiation therapy and chemotherapy and more specific about covering services such as podiatry, prosthetics, identification of developmental delays and wellness programs.

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Appendix: Partial List of Mandatory Services for Commercial Plans (Chapter 700c)

• Diabetes testing and self management training• Behavioral health, including biologically based conditions• Autism spectrum disorder therapies• Mammograms and breast ultrasounds• Certain Lyme disease treatments• Pain management• Ostomy supplies• Neuropsychological testing for children with cancer diagnoses• Mobile field hospital• Prescription contraceptives• Infertility treatment• Low protein foods

Appendix: federal funding opportunities

• PPACA includes a number of funding opportunities for preventive care, including:• 10 state wellness demonstration (Secs. 1201 and 4206)

• Grants for incentive programs to help Medicaid recipients quit smoking, control/reduce weight, lower cholesterol and blood pressure (Sec. 4108)

• Grants for community preventive health activities (Sec.4201)

• Pilots to promote healthy aging (Sec.4202)

• Demonstration to increase immunization of high risk populations (Sec. 4204)

• Support community-based collaborative care networks of providers to provide comprehensive coordinated and integrated health care services for low-income populations (Sec. 10333)

• Workplace wellness grants for small employers (Sec. 10408)