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

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