Green Mountain Care Board releases insurance plans for exchange, shoots down dental proposal

The Green Mountain Care Board on Tuesday shot down a proposal to require adult dental coverage on the Vermont health benefits exchange and approved six insurance plans, which will lay the foundation for the future health insurance market.

But this new marketplace carries caveats. The board is concerned that two of the six plans will leave Vermont’s low-income residents with high health care costs in times of greatest need.

“It is going to be a rugged undertaking if you have a bronze plan and you get sick,” said board member Al Gobeille. “I don’t want that sugarcoated. Everybody should know what is going on.”

As stipulated in the Affordable Care Act, Vermont’s exchange is slated to go into effect on Jan. 1, 2014. When it does, low-income health insurance programs like the Vermont Health Access Program and Catamount Health will cease to exist. As Lindsey Tucker, deputy commissioner of the Health Benefit Exchange put it, low-income Vermonters will either qualify for Medicaid or they will enter the exchange.

The two Bronze plans Gobeille referred to fall at the bottom of the state insurance hierarchy. Patients on these plans would pay the highest copays and receive the lowest coverage. Annual out-of-pocket expenses, which don’t include premiums, would tap out at $6,250 for medical services and $1,250 for pharmaceuticals. That amount is termed the “out-of-pocket maximum,” or OOPM, and according to Tucker is double for families, regardless of size.

Above those bronze plans are two silver plans, a gold plan and a platinum plan, which present patients with lower maximums and better coverage. State officials expect that plans with better coverage will have higher premiums. (See the chart above for a plan-by-plan comparison.)

The premiums for each of these plans, however, won’t be determined until the summer of 2013, when insurance companies submit their proposals to the Green Mountain Care Board, which is responsible for approving them. Premiums will fluctuate in price between individual and family plans, said Tucker.

According to the Green Mountain Care Board’s calculations, roughly 80,000 Vermonters will purchase health insurance via the exchange. That number represents those Vermonters who purchase insurance individually or are part of a small business with 50 or fewer employees.

In addition to this set of state-constructed plans, insurance companies will be able to propose several “choice plans” that are created within state guidelines. Those plans will be released at a later date.

Anya Rader Wallack, chair of the Green Mountain Care Board, doesn’t think the health benefits exchange will reduce the cost of health care for Vermonters.

“I think this particular decision has very little to do with restraining health care costs,” she said. “I think other activities we’re working on will do that, but this is just about how you structure insurance coverage in the market. It’s not about changing the health care system fundamentally.”

When asked about the bronze plans, she said that they are worrisome.

“I think all of us (on the board) have expressed some concern about the cost-sharing exposure at those levels,” she said. “If you’re someone who has extraordinary medical expenses, you can be insured and still have to pay for a lot of those expenses out of your own pocket.”

Wallack said that the Shumlin administration pressured the Legislature to draw up legislation preventing bronze plans. But business interests triumphed.

“Representatives of the business community argued that they wanted them to be available,” she said. “And they ended up prevailing in the Legislature and (the state is) keeping the bronze plans as part of the Vermont scheme.”

No adult dental benefits

In spite of 1,500 written comments calling on the Green Mountain Care Board to make adult dental benefits an essential health benefit on the exchange, the board decided in a 3-2 vote not to. Voting to make adult dental coverage an essential health benefit would have included dental coverage in all health insurance plans sold on the marketplace.

This split marked the first time the board did not unanimously agree on an issue. Con Hogan and Karen Hein were the two board members in support of providing dental benefits, while the other three members — Wallack, Gobeille and Allan Ramsay — did not. Dental and vision benefits for children are, however, essential health benefits.

Although all of the board members agreed that adult dental health is a crucial element of overall health care, the prevailing opinion was that they didn’t have enough information to determine what level of dental care was appropriate to put in adult plans on the exchange. Depending on the level of care, said Ramsay, this proposition could cost the state anywhere from $17 million to $87 million.

“I don’t think there’s anyone else on the board who has seen … the effect of dental care on a person’s quality of life more than me,” said Ramsay, who is a primary care physician. “I also saw the (positive) effect of opening a dental clinic at the community health center in Burlington when I was on the board. … That being said, I believe that when we reform and improve the health care system, we do so in a series of steps.”

“To make that system of exchange … work well I just can’t reconcile how we can add an additional financial burden to (Vermonters) at this point, at this step, in the process we’re trying to achieve. As painful as that is for me, I just can’t reconcile that issue.”

At the end of the meeting, Gobeille proposed that the board hire a professional to analyze current access to dental care, how it is financed and how it is organized. All board members supported this notion, and by Nov. 15, board director Georgia Maheras is tasked with drawing up a project outline.

Donna Sutton Fay, policy director of the Vermont Campaign for Health Care Security Education Fund, said she was glad the board plans to study the issue but wishes they would have spent more time analyzing funding.

“I’m really happy to hear that the board gets how important dental care is,” she said. “But I’m really disappointed that there was no discussion about funding. … One place funding could come from is the sugar-sweetened beverage tax.”

The soda tax floated by state officials in previous years was estimated to generate roughly $27 million for the state.

Clarification: Dental benefits can be included in health care plans and as stand alone plans on Vermont’s exchange. Adult dental benefits, however, are not essential benefits.

Andrew Stein

Comments

  1. Anna Carey MD :

    The financial burden of adding dental care to the Health Care exchange is real because the exchange is only a MASQUERADE of insurance companies to keep profiting from selling some very lousy health care plans (i.e., the Bronze plan), not reducing the costs of care. And yet, Karen Hein MD and Con Hogan, the two members of the Green Mountain Care Board who do champion dental health are to be applauded. Dental health, just like mental and ‘physical’ health provides essential and life-saving means for nutrition, growth, sustenance and last but not least toothy delightful smiles. Alternative revenues such as the ‘sin tax’ on tooth decay promoting products bear consideration.

    • Craig Powers :

      Your insistence that the bronze plans are lousy is an incorrect statement. They are excellent plans for some people to keep costs down. They are not “lousy” plans for everyone.

      • Paula Schramm :

        Bronze plans are certainly “excellent” if you can’t afford any other option.

        • Jesus Ortiz :

          With all due respect, when did we become so blind to reality that we think a health insurance plan that only covers 50% of an individual’s costs (or 90% for that matter) is ever ok? One bad accident or chronic health problem will bankrupt most people “covered” under any one of these plans. Try to imagine a $500,000 hospital bill and then try to imagine coming up with $50,000 (%10 of the total) or, for that matter, $250,000 (50%) in out-of-pocket costs. Healthcare is a human right and no one should face financial ruin just from getting sick.

          Second, if anything, these terrible plans urgently point to the very real need for government provided, universal healthcare. The citizens of every other industrialized nation on earth have high quality unlimited coverage that is fully paid for with their tax dollars. The never pay more than their tax bill for all the coverage they ever need. Why can’t we have the same? Why shouldn’t we have the same? When are we going to expect the same? When are we going to demand the same?

          • William Koch :

            Jesse, you misunderstand how these plans are structured. Yes, there is a lower co-pay for certain categories of service, but the out-of pocket costs are capped. The catastrophic medical event (cancer, organ transplant, severe trauma, etc.) would require $7,500 annually from the subscriber, with the rest of the costs covered by the insurer. Most insurance plans work this way now. Please remember that many individuals have HSA’s and Flex Plan monies available to help cover out-of-pocket expenses, and many businesses and employee groups have endorsed the combination of higher deductible, lower premium plans that are supplemented with these co-pay tools.

            Finally, as to health care being a “right”– it most certainly is not, any more than any other service or commodity. It very may appropriately be viewed as a basic necessity, but not a right. “Rights” in jurisprudence are concepts that protect the individual from intrusion or control by the government. Rights have limits, as we see from court cases, but the term is not used to describe entitlements.

          • Paula Schramm :

            In response to William Koch – I appreciate your effort to clearly define “rights” in jurisprudence, a helpful clarification. On the other hand we speak, ( famously in our Declaration of Independence), of having certain unalienable rights, including life, liberty and the pursuit of happiness, and of forming a government that “promotes the general welfare”. FDR was pushing an “Economic Bill of Rights” which talked about people’s rights to food, shelter, health, and work adequate to live in dignity. ( If only he had lived a bit longer ! )

            If we constrain our concepts of “rights” to your description, we wouldn’t have the right to eat, or even breathe…..clearly we function with a much broader understanding of rights than that, and the ethical standards and morality of our society and nation is rightly open for debate.

            All the other industrial democracies have made the ethical choice to make sure that ALL their citizens have access to affordable health care. This seems a civilized choice, and it works better for their populations than our choice does. This is one painful way that we truly are “exceptional”.

      • walter carpenter :

        If you want pay for insurance and not be able to use it in case you get sick or not mind paying the first $6,000 and change out of your own pocket then the bronze might just the plan. High deductibles are great for the insurance company because, while one pays the premiums, they cannot use the insurance without fear of medical debt.

        • William Koch :

          Walt, I have had a high deductible plan for many years, and I love it. Not everyone is broke, and some individuals choose to self-insure for the first few thousand because they have resources to do so. Health care utilization rises dramatically when there is no buy-in from the consumer, and these “bronze” plans suit certain individuals. Universal access to medical insurance is a great thing; providing limited or no choices in those plans is not.

          Insurance is meant to be a hedge against catastrophe, not a guarantee that every event– whether it be a fender-bender, a lightning strike to the house, a short-term disability, a tort claim, or an illness– is to be paid for by the insurer.

          Thanks for your comment.

          • Paula Schramm :

            “Health care utilization rises dramatically when there is no buy-in from the consumer”….

            William Koch-you explain why the bronze plan suits you : you have the resources to pay the deductible, and I’m guessing, you feel healthy enough that it seems like a sensible gamble.

            But the flip side of your phrase above is that for those who have the high-deductible insurance,( not because they are “broke” as you put it, but because they are working but can’t afford anything better ), their health care utilization drops dramatically. Why ? Because they can’t afford to get the care they need, so they put it off as long as they can.

            From a public health standpoint, as well as an ethical standpoint, this is a disaster.

    • rosemarie jackowski :

      Dr.Carey…Thank you. The exclusion of dental care will have disastrous consequences. How about instead to save money we fire those 3 members of the GMCB, fire the insurance companies,and cap the salaries of hospital CEOs. There is not a shortage of money – just a shortage of politicians willing to spend it in the right way.

      Many others pretend that Vermont is heading toward Single Payer. That will never happen until the insurance companies are out of VT.

      In the meantime, can I trade my obstetrical care for dental care. I’m 75 years old.

  2. Ann Raynolds :

    And it is true that healthy people can pay a penalty and have no insurance. Important always to state that creating these Exchanges is NOT the Single Payer Healthcare System which the GMCB is still tasked to design and present. Within THAT system, free of administrative profit-making by the Insurance companies, we will defnitely have to include a dental plan. I thank the supporters of dental care, am one of them and say: We won’t go away.

    • Robert Roper :

      But, if the cost of the dental plan causes the total cost of healthcare in Vermont to exceed what it is today, then the governor promises he will “take his marbles and go home,” and scrap single payer entirely. No? This, at least according to Shumlin, is primarily about cost control.

  3. Ethan Parke :

    Thank you to Con Hogan and Karen Hein for their principled dissent. Although the Exchange is only supposed to mirror the current insurance marketplace, the process of deciding what will be offered in the Exchange presented an opportunity for the Board to suggest a creative approach for adult dental care–which some employers now offer, and others do not. That the Board ran out of time, or chose to be cautious, is understandable, but unfortunate. I agree with Ann Raynolds that the next forum for a discussion on dental benefits will be in the single payer benefits and financing debate. Carry on!

  4. Lester French :

    Insurance is a shell game where many pay into a pool to provide support for the fewer number who need it. Administrative expenses and profits are taken off the top. Dental insurance would better be served by individual medical accounts paid into pre-tax than by paying an insurance company to administer the program. Preventive care is normally covered by insurance at an additional cost to the consumer. This cost would be avoided by a medical accounts program.

  5. Bruce Post :

    I appreciate all the work the Board has put into this, and it will be interesting to see what the price structure will be.

    As my wife and I have studied Medicare (I’m 65 today!), it is has been eye-opening to recognize that, just as in the exchanges, individuals essentially will have to do their own medical underwriting or risk analysis. In the exchange, someone can get a bronze plan, with its relative lower costs, and do just fine. This is similar to paying for Medicare Part B, the medical program apart from Part A, the hospital program. Medicare recipients can choose not to pay extra for a Medicare Supplemental program, and barring any large, unexpected medical problems, they have a good deal. Yet, if they suffer a serious illness or trauma that requires extensive and costly medical intervention, they are on the hook for untold extra costs. They simply bet wrong.

    To me, this is a fundamental and ethical problem with a system that involves numerous private payers, who can call on their phalanxes of actuaries and medical directors so that they can underwrite their risks. Individuals generally don’t have that level of sophisticated and technical understanding and comparable tools. And, as is often said, “You shouldn’t bet against the house.”

    Of course, a single payer (or the single “pipe” as some have called it) is not ipso facto a silver bullet. Governments around the world also price out their expected risks, and I am aware of very few government-sponsored systems that are not struggling with the same issues: demographics, technology, pricey interventions, etc.

    Still, I approve striving for single payer system of some variation, and as the decision about dental care shows, tough decisions will be necessary every step of the way.

  6. Kristin Sohlstrom :

    Be very, very careful about buying into the argument that the exchange is a soft and fuzzy portal through which to buy health insurance. Remember that other types of sites that are being used for comparison such as Kayak.com are sites you enter of your own free market will. That’s not going to happen with the health exchanges.

    http://www.cchfreedom.org/files/files/Exchanges_Portal_Map(1).pdf

  7. Eric Davis :

    Are the Green Mountain Care Board’s responsibilities policy-making, regulatory, administrative, or a combination of all three?

    It seems to me that the decision about whether or not to include adult dental health services in the exchange verges close to policy-making and is different in kind from the GMCB’s decision to ask some hospitals to resubmit their budgets because the original proposals were too high in comparison to the guidelines established by the Legislature.
    In the case of the hospital budgets, the Legislature established policy and charged the GMCB with regulating its implementation.

    The Legislature did make certain policy decisions about the exchange in 2012, for example not to allow individual and small group policies to be sold outside the exchange, and to permit the exchange to include bronze-level policies. Whether or not to cover adult dental care in the exchange seems similar to those sort of policy choices. Granted, the Legislature shouldn’t be micro-managing Vermont’s health care system, but some decisions rise to the level of policy-making rather than simply regulating or administering.

    If whether or not to include adult dental benefits is seen as connected to funding those benefits, and a tax on sugared beverages is a possible source of those funds, that make the decision about dental even more of a policy question for the Legislature – regardless of what one thinks about the merits of the sugared beverage tax.

    One other question: as I understand the exchanges, as of January 2014, all employees of businesses smaller than 50 employees must obtain their coverage through the exchange. If someone who works for such a business now receives adult dental health benefits through an employer-provided insurance policy, what happens to that employee after January 2014? Can the small businesses purchase adult dental group coverage for their employees (assuming such a product is available in Vermont), or will the employees have to go out and buy individual dental policies (assuming such policies are available at a reasonable price)?

    • Paula Schramm :

      Eric Davis, in answer to your question, here is an official summary of what the GMC Board has to do :

      Vermont’s Health Reform law, Act 48, charges The Green Mountain Care Board (GMCB) with controlling the rate of growth in health care costs and improving the health of Vermonters. The GMCB approves hospital budgets, major health care capital investments, health insurer rates increases, all-payer rates for all providers, and minimum health benefit requirements. The Board encourages Vermonters seeking to share their views to visit the GMCB website (http://gmcboard.vermont.gov/) or to call (802) 828-2177.

  8. Jay Davis :

    These plans seem to me on surface out rageous. All western countries have a single payer HC system. Our neighbor north, Canada has such a system/

    The crying and outrageous issue here is profits and Insurance companies as well as heath care provider excess treatments and out right frauds.

    We all should get basic healthcare as the Canadians do for no out of pocket payments. The whole concept is just making the day one year more, the system fails entirely.

    Younger people generally, outside, of some chronic illness just don’t need a full coverage, unless some medical emergency takes place.
    Perventive care early on, weight control, excercise, diet and drug abuse prevention save billions down the road.

    I have written Sandars often about the Draconian part B medicare catch 22. Everyone pays the same, currently 100 a month or 1200 a year plus a 170 dollar yearly decucible that is transfered to some co insurance.
    What a way to impoverish the elderly further on a 1100 a mont SSI. That is ten percent of a poverty income taken away fro part B coverage that has its own yearly co-pays and deductibles. This is a system that needs be scarped for a single pay No copay or robbing of an SSI allowance in a pemiums.

  9. John Greenberg :

    I’m not sure that I’m understanding the chart correctly. The top line show maximum out-of-pocket expenditures, but then other lines show less than 100% coverage.

    So if a patient has a $30,000 procedure in the hospital, for example, how much does he or she pay under each plan? Does the 50-90% coverage shown kick out and become 100% after the “out-of-pocket maximum” in each case, or is the patient left with a substantial bill to pay?

    I’m guessing that these are all zero deductible plans: that is, with the variables shown in the chart, they begin paying at the first dollar of billing? Is that correct?

    • William Koch :

      John,

      These plans appear to mimic what is currently available in the marketplace today. All of them have some form of deductible, but there are differences in deductible depending on what service is rendered. As an example, there is a greater co-pay for name brand vs. generic drugs. That said, there are aggregate annual maximums that limit out-of-pocket costs. The plans attempt to combine smart consumer spending with cost sharing, as dollar-one, 100% coverage plans are ridiculously expensive and do not discourage wasteful patient choices (e.g., if it costs the same, many patients would always opt for the name-brand drug, believing it to be better, as happens every day in drug stores when store brands are cheaper. Or, when patients use the ER for a case of the flu.) The plans are designed to allow businesses and individuals to choose their risk of cost exposure in exchange for lower premiums. No one plan suits everybody the same, just as we all have choices in collision deductible on our auto policies. The question is how much one wishes to self-insure for minor and routine medical expenses.

  10. What are the implications of healthcare reform on dental care? http://www.healthcaretownhall.com/?p=4883

  11. Len Vignola :

    My wife & I have been on Medicare A & B, VT Blue 65 (medicare supplement) & Blue Medicare RX for years and are very pleased with the coverage and costs. I have one question that no one has been able to answer; Can we continue to maintain these plans ?

  12. Dave Bellini :

    Excluding dental care is just a preview of coming attractions. All the altruistic song and dance of the past few years is fading away and AFTER THE ELECTIONS a new reality will become clear: This isn’t going to be as wonderful as advertised. Vermonters will still struggle to have medical care needs met, like dental. Will the new plans cover hearing aids, eye glasses, orthodontics, durable medical goods, etc? What happens when the economy tanks again? If we’re going to have a socialist takeover, let’s at least do it all the way and cover what is needed. BAD, AMORAL, DECISION – GMCB People need dental care.

  13. Christopher French :

    i think it’s really sad to not include dental for adults. at a minimum, 2 cleanings a year could help many people. i’m fortunate to have both dental and health through my partner. but i know many people won’t even be able to afford this.

  14. Anita Kelman :

    Both VHAP and Catamount are excellent insurance programs. I wonder why the new Exchange Plans are not more closely modeled on these, especially as Medicaid dollars help support VHAP at present, and would I gather also do so in the future after the Exchange takes effect.

    I also wonder why teeth are not considered part of the body for medical purposes? Given that it is well known that the health of the gums and teeth play major roles in overall health, let alone the ability of people to eat a healthy diet, just what do we save by leaving out dental coverage for adults? And when low-income Vermonters can’t afford dental care and lose their teeth they become the butt of sniggering “woodchuck” jokes, have difficulty finding work and are otherwise discriminated against.

    We need to do better than this set of plans. Somehow most if not all other industrialized nations manage to care for their citizens better than we do.

  15. Jim Barrett :

    It is always nice to have plans with no costs published by the very person who is pushing this farce….Shumlin! Just a note: the state doesn’t p[ay for my healthcare, I do. So when Shumlin claims the STATE is paying 5 billion a year now he is full of it………many take the responsibility of paying for their own insurance and I don’t rely on handouts from Shumlin!

    • Paula Schramm :

      Jim Barrett – my understanding from what Shumlin et. al. say, is that we all are now paying 5 billion a year for health care in this state…..counting the way that everyone pays for their health care, whether as part of a state program, or through a private plan. Does that make more sense to you ?

      • walter carpenter :

        “is that we all are now paying 5 billion a year for health care in this state…..counting the way that everyone pays for their health care,”

        Paula, yep. It is $5 billion for the whole tab — public, private, public-private, and rising by a million or so a day. I am curious to know what insurance Jim is on if he pays for it by himself, since so few can, and the ones I know who are paying for it by themselves are getting crushed by it.

  16. Lisa McCormick :

    This does not look like great coverage to me, especially for the folks who choose the bronze plan. I will assume such folks are probably the working poor who don’t qualify for Medicaid. They’re out of pocket max is over $6,000; their family max is over $12,000.

    Would the $1,250 Rx max be in addition to that? Considering that many poor people have chronic health conditions and need monthly prescriptions, they may have to shell out a big portion of their monthly income before the $5 copays kick in.

    I’m curious to see what the premiums will look like. Most Vermonters won’t be able to afford several hundred in premiums, plus all of the out-of-pocket expenses in the above chart.

    It will only get worse. I have a feeling a lot of people are going to end up paying the tax penalty once Obamacare goes into effect, simply b/c they won’t be able to afford the available health care plans.

    The only plan that I could fathom working would be Medicare for all with the option of purchasing a supplemental gap plan. This works quite well in France and Australia among other countries.

    As far as dental care is concerned, I could understand why it would be a deal breaker financially even though everyone should be able to have the basics: cleanings and fillings. Not sure how this should be handled. I don’t think dental care is standard in all of the European countries that offer universal care.

  17. Why cannot we have, as part of our plan, a form of cafeteria plan~~i.e. not have obstetrical (I am 78) and replace with dental? It seems to me that if we could have some choices within a plan, this would be far more acceptable to more folks…..

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