As a result of the Affordable Care Act, new federal requirements raised the status-quo for all health insurance plans operating in the District of Columbia. Beginning in 2014, health insurance plans were required to offer a more robust package of benefits known as essential health benefits (EHB). At that time, the District of Columbia selected Group Hospitalization and Medical Services, Inc. BluePreferred PPO Option 1 as its benchmark plan for reference of inclusion of EHB. The DC Department of Insurance, Securities and Banking (DISB) is collaborating with the DC Health Benefit Exchange Executive Board to decide on a new benchmark plan for the 2017 plan year, based on plans which were in place in 2014. As part of that process, a meeting of the Standing Advisory Board is happening on May 21 where public comment is being taken. For information on the May 21 meeting of the DC Health Benefit Exchange Standing Advisory Board, follow this link.
At a minimum the benchmark plan must include the following 10 Essential Health Benefits:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and management of chronic diseases
- Pediatric services, including oral and vision care
Benchmark Plan Selection Process
The District of Columbia must notify the Center for Consumer Information and Insurance Oversight (CCIIO) of its plan selection no later than July 1, 2015. All plans certified for sale on DC Health Link which were offered in the District during the 2014 plan year included the EHB as referenced above. However, Federal guidance allows the District to select a benchmark plan from a list of 10 benchmark offerings. Plans that do not currently meet the EHB requirements and / or previously established coverage mandates established by the Council of the District of Columbia may include the Federal Employee Health Benefit Plans (FEHBP), State Employee Health Benefits and the Largest Commercial HMO. In the event that one of these plans is selected, the selection committee will use the other benchmark options to supplement any EHB category that is not covered under the selected plan. For example, some visit limitations on mental health services are not permissible because the benchmark plan must comply with the federal parity law. Plans offered in the District already comply due to HBX resolution, whereas, since state employee plans, the largest commercial HMO, and the FEHBP are not-ACA compliant plans and exempt from some District mandates, they may not comply and may in turn require a greater degree of supplementation.
Specifically, Federal guidance requires the selection committee to assess the following ten plans using enrollment data from the first quarter of 2014 (March 31, 2014):
- Three largest small-group plans
- Three largest state employee health plans
- Three largest federal employee health plans
- Largest commercial HMO plan
In order to facilitate a transparent selection process, DISB is providing information on the ten benchmark options. The documents below provide detailed information about each of the plans being assessed in the selection process.
LARGEST SMALL GROUP PLANS
- GHMSI BluePreferred PPO (Form and Schedule of Benefits)
- CareFirst HealthyBlue Advantage (Form and Schedule of Benefits)
- Kaiser HMO SG Off Exchange HMO (Form and Schedule of Benefits)
LARGEST FEDERAL EMPLOYEE HEALTH BENEFIT PLAN
- Blue Cross Blue Shield FFS Standard Plan (Form and Schedule of Benefits)
- Blue Cross Blue Shield FFS Basic Plan (Form and Schedule of Benefits)
- Government Employee Health Association Plan FFS Standard (Form and Schedule of Benefits)
STATE EMPLOYEE HEALTH PLAN
- Aetna HMO Plan DC Gov (Form and Schedule of Benefits)
- Aetna PPO Plan DC Gov (Form and Schedule of Benefits)
- Kaiser HMO Plan DC Gov (Form and Schedule of Benefits)
LARGEST INSURED COMMERCIAL NON-MEDICAID HMO
DISB looks forward to receiving public comments on the benchmark plan candidates. Public comments will be accepted through May 31, 2015 and will be shared with the Health Benefit Exchange Standing Advisory Board to inform their decision. Comments are to be sent electronically to [email protected].