BlueCross BlueShield PPO may be TN plan

7:55 AM, Oct 4, 2012   |    comments
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By Getahn Ward | The Tennessean

A decision by Gov. Bill Haslam against setting minimum benefits that health insurers would have to offer for individual and small-group coverage here starting in 2014 could make a plan from BlueCross BlueShield of Tennessee the benchmark for the state.

Under federal guidance to implement health care reform, if a state chooses not to select a so-called essential health benefits package, the federal fallback option would be the largest small-group plan available as of March 31. In Tennessee, that's a BlueCross preferred provider organization plan that had 92,836 people enrolled as of that date. But the U.S. Department of Health and Human Services could still require modifications to that default plan after gathering feedback from the public.

HHS encouraged states to submit their essential health benefits benchmark by Monday, but it is expected to continue to accept benchmark plans throughout this month. The essential benefit requirements would apply to individual and small-group plans sold within and outside new online, state-based exchanges where individuals and small businesses can shop for coverage.

In a letter to HHS Commissioner Kathleen Sebelius on Sunday, Haslam cited three reasons for his decision not to select a benchmark plan. He cited states' options being extremely limited because the federal government defined health plans from which they must choose; individual states' decisions would only stand for two years before the feds dictate the essential health benefits for all states; and a lack of guidance, clarity and information needed for states to make responsible and informed decisions.

As of Monday, 24 states, including Arkansas, California, Kentucky, Mississippi and Nebraska, had selected and submitted benchmark plans, according to Avalere Health, a consulting firm in Washington, D.C. So far, Tennessee and Alabama are among states that decided not to choose one. Several other states have yet to make their intentions known as they wait for additional HHS guidance.

In many cases, states that have selected a benchmark plan chose the same plan that would have been the default option or federal fallback option, said Caroline Pearson, director in the health reform practice at Avalere. "Certainly, the default is a reasonable benchmark," Pearson said.

The reform law required coverage under 10 main categories, such as preventive care, emergency services, maternity care, prescription drugs and hospital and doctors' services, but left it to the states to determine specific benefits offered within those general categories by selecting a benchmark plan from which benefits must be based.

At first glance, Pearson said the major differences across the benchmark plans that Tennessee could choose from centered on coverage for mental health/substance abuse services and autism therapy. The default BlueCross PPO plan includes some service limits the other benchmark plans don't, she said. She noted that was consistent with what Avalere is seeing in other states, where the key differences across the possible benchmarks are in coverage for autism, mental health and rehabilitative services.

In Haslam's letter to Sebelius, he mentioned public forums and requesting insurance companies to compile data on their potential benchmark as part of the due diligence performed by state officials before he reached a decision.

Tennessee officials face a separate Nov. 16 deadline to let the federal agency know whether they plan to run a health exchange.

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