New York Selected EHB Benchmark – Oxford EPO

Posted October, 4 2012 by arianne

On Monday, October 1, New York State selected the benefits of the State’s largest small group plan, Oxford EPO, as the Essential Health Benefits (EHB) benchmark plan.

The state also outlined the coverage areas in which the Oxford plan’s benefits will be supplemented to meet ACA requirements:

  • Pediatric dental/vision coverage – NYS will supplement the Oxford plan’s benefits with the current pediatric dental/vision benefits offered through NY’s CHIP coverage.
  • Habilitative services – will have parity with rehabilitative services.
  • Mental health/substance abuse parity – benefit limits in the Oxford plan will be removed.
  • Annual/lifetime dollar limits – quantitative limits will be substituted when further federal guidance is available.

As we explained in our August 13 post, the selected benchmark EHB will apply to all non-grandfathered plans both inside and outside the State Health Insurance Exchange (the Exchange), as well as the benefits included in a Basic Health Plan, if New York implements such a plan.

In our written comments to the State, HCFANY urged the State to select the New York State Employee Plans’ Empire Plan, which has more comprehensive benefits than the Oxford plan. Among other differences, the Empire Plan covers adult dental care, and covers some services (like physical therapy and speech therapy) according to medical necessity rather than limiting those services to a set number of visits.

The State balanced value to consumers and small business employees of the more comprehensive benefits with the predicted additional cost these benefits would add to premiums. According to Milliman, the consultant that studied the EHB benchmark options for the State, selecting the Empire Plan would add $15 more to monthly premiums than selecting the Oxford plan would. The complete report by Milliman on EHB is available here.

The State received extensive feedback, including 60 written comments from the public.  Some of the comments, like this comment from the Hemophilia Association of New York, urged the State to select the Empire Plan because consumers need comprehensive coverage. Others, including this comment from the New York State Conference of Blue Cross and Blue Shield Plans urged the State to select an Oxford plan to keep premiums lower.

Input at the Regional Advisory Committees was similarly mixed, with stakeholders including carriers and small business advocates urging the State to keep premiums low, and stakeholders including consumer advocates urging the State to choose a more comprehensive benefit package.

While consumer advocates are disappointed in the State’s decision, there are some consolations for consumers:

  • The EHB will serve as a floor, not a ceiling, for benefits offered by individual and small group plans in New York.
  • The EHB will raise the floor for many New York consumers, including consumers who currently have coverage through Healthy NY plans.
  • Benefits that are not covered by the EHB, like adult dental, will be available through more comprehensive plans or coverage riders.
  • The EHB decision may be revisited for 2016.

HHS will offer the public one more opportunity to comment on this decision through a Notice of Proposed Rulemaking. We will keep you posted about opportunities to comment at that time.