Kansas health plans might have to cover more services for children starting in 2014.
Consultants in the Denver office of Milliman Inc. raise that possibility in a report prepared for the Kansas Insurance Department.
Department officials asked Milliman to help them compare the existing Kansas health plans that might serve as the benchmark plan the state needs to choose to comply with the essential health benefits (EHB) provisions of the Patient Protection and Affordable Care Act of 2010 (PPACA).
All of the 9 candidate plans offer similar benefits, and all fail to cover at least one of the benefits required by the PPACA EHB provision, the Milliman consultants say.
"All plans fail to fully cover habilitative services, as well as both pediatric oral and vision coverage," the consultants say.
When Kansas uses the real-world plan it picks to be the model for the EHB package, it probably will have to add habilitative services, pediatric vision care and pediatric dental care benefits to the package, the consultants say.
All Kansas would have to do to flesh out the pediatric oral and vision benefits package would be to add benefits provided by a plan other than the EHB benchmark candidate plans, such as the Kansas Children's Health Insurance Program, the consultants say.
Adding habilitative services benefits may take more work, the consultants suggest.
The EHB Program
If the law takes effect on schedule and works as drafters expect, it will require all individual and small group major medical plans to offer the standardized EHB package by 2014, to help consumers compare coverage and reduce gaps in coverage.
The U.S. Department of Health and Human Services (HHS) has asked each state to design its own EHB package. A state is supposed to start by looking at the benefits offered by the three largest Federal Employee Health Benefits Program plans offered in the state, the three largest state employee benefit plans, the three largest small group commercial health plans, and the largest commercial health maintenance organization (HMO) plan.
A state is supposed to look at the 10 candidate plans when choosing the final EHB benchmark plan. Milliman left commercial HMO plans out because Kansas has no large, statewide commercial HMO, the consultants say.
The final EHB benchmark plan is supposed to offer benefits in 10 different areas, including ambulatory patient services, emergency services and hospitalization as well as a pediatric services category that includes pediatric oral and vision health services and a category that includes both rehabilitative and habilitative services.
PPACA calls for the EHB plan to provide comparable coverage for rehabilitative and habilitative services.
The term "habilitative services" refers to speech therapy, occupational therapy, and other services "focused on assisting individuals in acquiring new and maintaining existing skills or functions typically gained through standard growth and development," the Milliman consultants say.
Some adults might use habilitative services, but health policy specialists say the major users likely would be children who have problems such as autism or Down syndrome that interfere with their ability to learn.
"Many health plans already cover some limited physical, occupational, or speech therapies to individuals with genetic or congenital conditions that might be considered 'habilitative,'" the consultants say. "It is far less common for private health insurers to provide coverage for services that may be considered educational or custodial in nature."
Today, the Kansas state employee plans are the EHB candidate plans that provide the strongest habilitative benefits, including autism-related services, the consultants say.
Putting an autism services benefit similar to the state employee plan benefit in the EHB package would help people who need those services, "but the expected costs of such a benefit are not well defined," the consultants say.
State officials will have to consider questions such as how habilitative coverage requirements will affect the cost of a plan and whether access to the benefit might lead to adverse selection, the consultants say.