Agencies Seek Information on Value-Based Insurance Designs

The Departments of Labor, Health and Human Services, and the Treasury have issued a request for information on how group health plans and health insurance issuers can employ value-based insurance designs (VBID) in the coverage of recommended preventive services, as required by the new health care law. The Affordable Care Act added a new section to the Public Health Service (PHS) Act that requires non-grandfathered group health plans and health insurance issuers offering group or individual health insurance coverage to provide coverage for recommended preventive services without imposing cost-sharing requirements. A complete list of such items and services that are required to be covered can be found under the applicable interim final regulation. Among other things, the interim regulations clarify that if a recommendation or guideline for a recommended preventive service does not specify the frequency, method, treatment, or setting for the provision of that service, the plan or issuer may use reasonable medical management techniques to determine any coverage limitations. Therefore, as explained in the Federal Register notice, “a plan or issuer may rely on established techniques and the relevant evidence base to determine the frequency, method, treatment, or setting for which a recommended preventive service will be available without cost-sharing requirements to the extent not specified in a recommendation or guideline.”

The interim regulations also recognized the “important role that value-based insurance design can play in promoting the use of appropriate preventive services.” Therefore, in preparation for drafting additional guidance on VBID, the agencies are seeking information on specific examples and best practices of VBID for recommended preventive services, as well as data used to support and inform VBID benefit design, measurement, and evaluation in the context of recommended preventive services. To that end, the request for information solicits comments in response to a number of specific questions, including:

• What impact would expanded use of VBID methods have on small employers or small plans? Are there unique costs or benefits for small plans? What special considerations, if any, should the Departments take into account for small employers or small plans?
• What specific plan design tools do plans and issuers currently use to incentivize patient behavior, and which tools are perceived as most effective (for example, specific network design features, targeted cost-sharing mechanisms)? How is effective defined?
• Do these tools apply to all types of benefits for preventive care, or are they targeted towards specific types of conditions (for example, diabetes) or preventive services treatments (for example, colonoscopies, scans)?
• What are the criteria for adopting VBID for new or additional preventive care benefits or treatments?
• Do plans or issuers currently implement VBIDs that have different cost-sharing requirements for the same service based on population characteristics (for example, high vs. low risk populations based on evidence)?
• How are consumers informed about VBID features in their health coverage?

Comments are due on or before February 28, 2011, and must be identified by VBID. Comments may be made electronically through the federal eRulemaking portal, via email to E-OHPSCA-VBID.EBSA@dol.gov, or mailed or hand-delivered to: Office of Health Plan Standards and Compliance Assistance, Employee Benefits Security Administration, Room N-5653, U.S. Department of Labor, 200 Constitution Avenue, NW., Washington, DC 20210, Attention: VBID.

This entry was written by Ilyse Schuman.

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