Forging Green Mountain Care: The benefits package

MONTPELIER -- Part of the uncertainty and trepidation surrounding Vermont's transition to a publicly financed health care system is about what services the program will cover.

While the administration continues to hammer out the details of a benefits package, there are some elements that are certain to be included.

Act 48, the state's health care reform law, establishes a floor for the benefits package, but leaves room for further discussion of what might be added.

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VTDigger will look at cost-sharing in the state's planned universal health care program, exploring what out-of-pocket costs Vermonters might face under their Green Mountain Care health plans.

That baseline of services includes primary care, preventive care, chronic care, acute episodic care and hospital services and must include at least the same covered services as those contained in the benefit package for the lowest cost Catamount Health plan.

When the law was passed, the federal government hadn't defined the minimum benefit package for health plans to be in compliance with the Affordable Care Act.

For instance, Catamount Health plans did not cover pediatric dental and vision care, which the Affordable Care Act requires.

The feds ultimately settled on a set of 10 essential health benefits, which include:

ambulatory patient services;

emergency services;


maternity and newborn care;

mental health and substance use disorder services, including behavioral health treatment; prescription drugs;

rehabilitative and habilitative - aiding normal function - services and devices;

laboratory services;

preventive and wellness services;

chronic disease management;

and pediatric services, including oral and vision care.

To receive a waiver to the Affordable Care Act allowing the state to transition to a state-run universal health care program, the benefits package could not offer less than what is required federally.

The Senate recently passed a health care reform bill that updates the benefit package for Green Mountain Care to consist of the essential health benefits for Vermont Health Connect, the state-run online insurance marketplace.

In defining what would be required of plans offered through Vermont Health Connect the state added mandates beyond what is required federally.

At the time, some lawmakers and advocates pushed for coverage of additional services, and are likely to do so again with Green Mountain Care.

Now advocates say the language in the Senate-passed bill is problematic, because it sets the current Vermont Health Connect benefits as the ceiling for a Green Mountain Care benefits package. That essentially means that no additional services could be offered, they say.

Act 48 explicitly requires the Green Mountain Care Board to consider whether the program's benefit package should include vision, hearing, dental and long-term care services.

If lawmakers set the benefits package before the board vets it, then not only does it create statutory confusion, they can expect to get an earful from advocacy groups that plan to push for more covered services, said Falco Schilling of the Vermont Public Interest Research Group.

"It makes a lot of sense for the board to take up that issue in an open public process as they did with the essential health benefits for Vermont Health Connect," Schilling said.

Changes to the health care reform bill, S.252, are currently being considered in the House Health Care Committee.

Schilling told lawmakers on the committee that changing the bill's language to make the Vermont Health Connect benefits package the floor would allow the process to play out as Act 48 envisions.

A more generous benefits package will increase the program's cost in one of two ways.

It will either necessitate additional tax revenue, pushing the state's portion of the program's cost toward the higher end of the current estimated range, or it will require Vermonters to pay more in out-of-pocket costs.


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