Kansas postpones benefits package autism services decision

Kansas Insurance Commissioner Sandy Praeger (AP Photo/John Hanna) Kansas Insurance Commissioner Sandy Praeger (AP Photo/John Hanna)

A Kansas regulator is suggesting that her state take a generous approach to covering pediatric oral and vision benefits but wait on making a decision about services for children with autism and other developmental problems.

Kansas Insurance Commissioner Sandy Praeger has included those thoughts in a package of recommendations for the Kansas essential health benefits (EHB) benchmark plan.

Praeger has suggested that Kansas should use the Blue Cross Blue Shield of Kansas Comprehensive Plan -- the Kansas small group plan with the largest enrollment -- as the foundation for its EHB benchmark.

"This plan represents a good balance of cost and benefits," and adopting a version of the plan as the state benchmark plan "should cause the least disruption in the marketplace," Praeger said.

One challenge, however, is that the Blue Cross Blue Shield plan lacks the pediatric dental, pediatric vision and "habilitative" development support services required by the Patient Protection and Affordable Care Act (PPACA) EHB provisions.

The EHB package

PPACA opponents continue to fight the law in the courts, in Congress, in state legislatures and at the polls

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, in an effort to help consumers compare plans on an apples-to-apples basis.

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.

The EHB benchmark plan chosen must provide benefits in 10 different areas, including ambulatory patient services, emergency services, hospitalization services and pediatric oral and vision health services.

HHS has been telling states to keep solid, affordable small group plans in mind, rather than deluxe benefit plans, when developing the EHB benchmarks.

In states that fail to develop EHB benchmarks, HHS will choose the benchmark plan.

In Kansas, the HHS EHB default plan would be the Blue Cross Blue Shield small group plan, Praeger said.

Because the Blue Cross Blue Shield plan provides no pediatric oral and vision coverage, the HHS default for those benefits would be the Federal Employees Dental and Vision Insurance Program.

Kansas had consultants from Milliman compare the Kansas EHB candidate plans.

The plans are similar and meet most PPACA requirements other than the pediatric services and the habilitative services requirements, Praeger said.

The term "habilitative services" refers to speech therapy, occupational therapy, and other services for children or others who have been born with handicaps, as opposed to rehabilitative services for patients who have lost abilities due to illnesses or accidents. 

At a recent hearing, a witness from Ameritas suggested that Kansas could base the required oral health benefits on the benefits provided by a typical small group plan. 

Tonya Dorf Brunner, executive director of Oral Health Kansas, a group that represents dentists and nonprofit dental plans, asked Praeger and other officials to base the pediatric oral health standards on the Children's Health Insurance Program (CHIP) pediatric dental benefits.

"Selecting CHIP provides more continuity of care between CHIP and the marketplace and would result in less disruption as families transition between CHIP and the Kansas private insurance market," Praeger said.

None of the EHB candidate plans provides the kinds of autism benefits and other habilitative benefits that apparently are required by PPACA, Praeger said. 

Praeger said HHS will release more guidance on the matter later this fall. "At this time, we do not know to what extent autism benefits, such as those currently included in the Kansas State Employees' Health Plan, may be included as a part of habilitative services," she said. "There fore we make no specific recommendation about habilitative services at this time."

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