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State selects blueprint for health exchange benefits

By Colleen Siuzdak
Staff writer

New York state has submitted its blueprint for a health benefit exchange to allow individuals and small groups to browse options for health insurance. The state Health Department chose a benchmark plan as a standard for insurance companies who wish to participate in the exchange. Photo by AP.
November 26, 2012
State officials have submitted a blueprint for the health insurance coverage that will be made available under the health benefits exchange that was established through an executive order in April.

Required under the Patient Protection and Affordable Care Act, the New York Health Benefit Exchange will serve as a marketplace where individuals and small business owners can browse options for health insurance. The exchange will depend on federal grant money until January 1, 2015, when it will then be required to be self-sustaining.

Goals of the exchange, according to its supporters, include increasing the number of insured New Yorkers by about 1 million people and increasing those covered by Medicaid and the Children's Health Insurance Program by about 500,000 people.

Peter Constantakes, spokesman for the state Health Department, said New York submitted the Blueprint for Exchange Readiness last month, based on the Oxford Exclusive Plan Metro health plan as the standard benchmark. The Oxford EPO model, the largest small-group plan in the state, most closely matched the ten requirements the federal government wants the states to include in their exchanges, Constantakes said.

The ten requirements that must be covered in the essential health benefit plans, according to the federal Affordable Care Act, are listed in a report prepared for the New York State Health Department by consultants Milliman, Inc. Those requirements include: ambulatory patient services; emergency room services; hospitalization; maternity and newborn care; mental health and substance abuse disorders; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric service, including oral and vision care.

"[This] benchmark looks at comprehensive benefits and affordability. This plans looks like it is affordable we want people to have those options," said Constantakes. According to a letter to the federal Health and Human Services agency from Donna Frescatore, executive director of the New York State Health Benefit Exchange, the Oxford EPO plan provides "comprehensive benefit coverage to consumers while minimizing costs to both the individual and small group markets."

According to the report, Oxford EPO coverage includes up to 210 days of hospice care combined with inpatient and outpatient days, up to 60 days for physical therapy inpatient and outpatient days, and up to 7 days of inpatient detoxification for rehab services. Medically necessary abortion is covered for abortions in cases of "rape, incest, or fetal malformation." Elective abortion is covered "subject to benefit limits" and "may be excluded based on religion."

Constantakes said the state is on schedule to implement the exchange by the required date of Jan. 1, 2014 and applications will be accepted beginning Oct. 1, 2013.

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