Come 2014 virtually all Utahns must have health insurance. But what will it cover, and how much will it cost?
Utah is a step closer to answering those questions the Legislative Health Reform Task Force decided unanimously Thursday to choose as a benchmark one of the high deductible plans available to public employees.
Lawmakers picked the Public Employee Health Plan's (PEHP) "Basic Plus" policy over the protests of low-income and mental health advocates who worry it sets the bar too low.
But task force Chairman Rep. Jim Dunnigan, R-Taylorsville, stressed, "This is the absolute bare minimum that must be offered. Insurers can, and certainly will, offer more."
Defining an "essential benefits" package is a requirement of federal health reform. It applies only to policies sold to individuals and small businesses, not large employer plans.
The task force's decision isn't binding. Its recommendations now go to the Utah Insurance Commissioner, who will issue emergency rules that must be endorsed by the U.S. Department of Health and Human Services in time for insurers to market plans in October 2013.
"We'll review what they've sent us and supplement according to federal rule," said Nancy Askerlund, the commissioner's health and life insurance director.
Lincoln Nerhing, a health policy analyst at Voices for Utah Children, predicts, "Where things are going to get interesting is if the feds say the plan doesn't jive with federal rules."
Utah had to base its benchmark on top-selling policies on the market, including federal, public and small business plans.
At minimum, it must cover emergency services; hospitalization; maternity, newborn and pediatric care, including dental and vision services; mental health and substance-abuse treatment; prescription drugs; rehabilitative and similar services; medical devices; lab tests; prevention and wellness; and chronic disease management.
PEHP's "Basic Plus" covers the bases, but the devil is in the details.
It doesn't, for example, specifically guarantee coverage of autism therapy or substance abuse treatment. Dental and vision coverage is limited to two check-ups a year for kids ages 3 to 18 and one eye exam for kids 5 to 18.
Also not covered: eyeglasses, hearing aids, orthotics and prosthetics, other than for the eye and breast reconstruction following surgery for cancer. Therapies for the disabled don't include residential group home treatment. And coverage for prescription drugs is limited to a formulary of mostly generics.
"One of our higher costs is prescription drugs," warned Tomi Ossana, director of Utah's high-risk pools, insurers of last resort for people whose pre-existing conditions make them uninsurable. In 2014 these patients will transition to private insurance, Ossana said.
"We have an individual [with a rare genetic disease] who gets a shot every month and it's $50,000. Is that covered as a medical benefit or a drug?" she asked.
PEHP Executive Director Chet Loftis said autism and substance abuse therapy can fall under behavioral health. Specialty drugs, such as insulin for diabetes and cancer therapies, are sometimes billed as a medical benefit, he said.
But those gray areas make county mental health and substance abuse providers nervous. The PEHP plan will pay to hospitalize someone for mental illness, but covers only eight outpatient behavioral therapy visits a year, which doesn't suit patients' needs and ends up being more expensive, said Adam Trupp, legal counsel for Utah's Association of Counties. "This is a chronic disease and something that needs to be treated as a chronic disease."
Lawmakers contend they had to strike a balance between coverage that's comprehensive and affordable.
The "Basic Plus" plan carries a $3,000 deductible per person and $6,000 deductible per family. It covers 70 percent of medical and drug costs with patients picking up the rest.
Dunnigan stressed these hard numbers didn't factor into Thursday's decision, since prices will vary by insurer. But it does set the actuarial floor upon which prices will be set.
"We want to be careful about getting too rambunctious in ramping up benefits because it will hike costs and reduce people's choice," Dunnigan said.
Utah lawmakers picked the state Public Employee Health Plan's "Basic Plus" policy as the benchmark for the state's future bare minimum health plan. Here's what it covers and excludes:
• Primary, pediatric, specialty, emergency and urgent care, hospitalization and surgery
• Preventive care, such as well check-ups and cancer screens, at zero out-of-pocket cost to patients
• Medically necessary lab and genetic tests and X-rays
• A formulary of prescription drugs
• Two annual pediatric dental check-ups, dental sealants and one pediatric eye exam
• Maternity, newborn care
• 30 days a year at a skilled nursing center
• 6 months of hospice care
• 30 days of inpatient mental health care
• 8 behavioral therapy visits
• 20 days of physical, occupational or speech therapy
• Eyeglasses and adult vision and dental care
• Hearing aids
• Allergy injections
• Smoking cessation services
• Autism therapy
• Infertility treatment
• Prosthetics, other than for the eye and breast following surgery for cancer
• Residential group home treatment
• Weight loss services
• Genetic testing
• Acupuncture, chiropractic office visits, massage therapy, cosmetic surgery