Dec. 06--Blue Cross Blue Shield of N.C. said today that a study saying the state will have the nation's lowest level of covered pharmaceutical drugs in its 2014 health-insurance exchange was wrong because Blue Cross submitted incorrect data.
A report released Tuesday by health-analysis group Avalere Health LLC estimated a N.C. health exchange could cover just 485 of 1,070 basic prescription drugs approved by the Food and Drug Administration.
Blue Cross spokesman Lew Borman said he did not know how many more drugs would be covered, but the number would be boosted "significantly higher."
The formulary, or lists of drugs, that will be the default benchmark for North Carolina is projected to be the Blue Options PPO (preferred physician organization) plan offered by Blue Cross. The insurer holds a 76 percent market share statewide for PPO products.
Borman said today a data-submission error by the insurer to the U.S. Department of Health and Human Services caused the listing of the wrong number of basic prescription drugs to be covered.
About 700,000 North Carolinians with limited or no insurance would be eligible to buy coverage through the exchange, according to studies. The health-insurance exchanges are required by the national Affordable Care Act.
The exchanges would affect North Carolinians in the individual and small-group insurance categories. States can set the maximum number of employees considered to be in a small group. Although analysts expect the average maximum will be 50, they said it could be as high as 100.
Avalere based its projections on data released Nov. 20 by the Centers of Medicaid and Medicare Services on state-selected benchmark formulary plans. Medicare received its data from the U.S. Department of Health and Human Services.
Borman said the insurer determined the data-submission error after reviewing the Avalere report. It has resubmitted the full formulary data to the federal agency.
"Blue Cross offers broad coverage of generic and brand name drugs through Blue Options, with different plans at different premium price points," Borman said.
North Carolina is one of 12 states currently listed in the bottom quartile for basic pharmaceutical drugs covered by a state's default benchmark formulary.
Virginia and West Virginia are projected to be among the 12 states whose exchange covers more than 99 percent of these drugs.
At the 485 drug coverage total, Avalere said North Carolina consumers would have access to essential medications, but some people might not have as much choice involving generics and brand names.
The state's health-insurance exchange must be finalized and operational by Oct. 1 so that residents can begin signing up on that date, for coverage to begin Jan. 1, 2014.
Caroline Pearson, a director with Avalere, said North Carolina has until Dec. 26 to decide upon a benchmark formulary.
Pearson said today Avalere has not spoken with Blue Cross directly since its report.
"I am not surprised that there is a data error," Pearson said.
"For example, there were 27 classes (pharmaceutical categories) that indicated no drugs were covered. We felt sure that wasn't going to be left that way.
"The exchange plans would have the flexibility to offer more drugs, but not below the default benchmark formulary amount."
Adam Linker, a health-policy analyst at the left-leaning N.C. Justice Center, said the state is facing two logistical challenges regarding health-care benefits.
North Carolina lawmakers did not establish the framework for a state-run insurance exchange in time for an initial launching in late 2013. Another option was to let the federal government run the exchange, which at least 18 states are doing.
Gov. Bev Perdue said Nov. 15 that North Carolina and the federal government will jointly run the state's health insurance exchange. Perdue, a Democrat, said she consulted with Gov.-elect Pat McCrory, a Republican, on the partnership.
McCrory said in a statement that Perdue's decision leaves flexibility for the future. The hybrid system can be changed later to an all-state or all-federal management.
Although the largest issue may be the health exchanges, Linker said the state also has to determine an essential health-benefit package that would be available through the exchange, as well.
"You could have a fully state-based exchange and still have a default benefit package," Linker said. "Or you could have a fully federal exchange and have a state-designed benefit package.
"The extended health benefits are just a proposed rule right now, with the federal government taking comments before finalizing the rule. So everything is up in the air right now."
Linker said citizens could make the case that the State Health Plan is the best benchmark for essential health benefits, rather than Blue Options PPO.
"If these comments convince federal HHS officials, then they could change our benchmark," Linker said.
The state has other issues to determine, including which wellness, pediatric dental and pediatric vision benefits the exchange will be required to offer, Linker said.
(c)2012 Winston-Salem Journal (Winston Salem, N.C.)
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