1、Jina DhillonJD,MPH“Securing Health Rights for Those in Need”Essential Health Benefits Roadmap Background Overview of HHS Bulletin Key concerns and advocacy responseBackground Secretary must define essential health benefits(EHB)package EHB must be equivalent to typical employer coverage EHB must cove
2、r ten categories of services ACA 1302Background Ten Categories Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health,substance abuse,behavioral health Prescription drugs Rehabilitative&habilitative services&devices Laboratory Services Preventive and
3、wellness services,chronic disease management Pediatric,including oral&vision careACA 1302(b)(1)HHS Bulletin Intended Regulatory Approach EHB will be defined by reference to a benchmark plan selected by each State from following four general categories(2014 and 2015):Largest plan in any of three larg
4、est small group insurance products*;Any of largest State employee health benefit plans;Any of largest three national FEHBP plan options;OR Largest insured commercial non-Medicaid HMO*If State does not select a benchmark,this is the default.HHS Bulletin Benchmark Approach and 10 Categories Benchmark
5、approach intended to satisfy 1302(b)(2)(A)requiring EHB to reflect scope of“typical employer plan”To satisfy requirement to cover all 10 categories in 1302(b)(1),State may need to supplement benchmark plan if the benchmark offers no coverage in a category of benefits*Most commonly non-covered catego
6、ries,as identified by HHS,are habilitative services and pediatric oral and vision services.HHS Bulletin States cover costs of benefits beyond EHB ACA requires that State must pay for mandated benefits in excess of EHB For 2014 and 2015,if State selects benchmark subject to mandates,those mandates ar
7、e part of the States EHB package and State would not have to defray those costs.HHS Bulletin Benefit Design Flexibility Health plans given flexibility to offer benefits that are“substantially equal”to benefits of the benchmark plan selected by State,as modified to meet 10 categories Health plans can
8、 adjust benefits(both specific services and/or quantitative limits)so long as they continue to cover all 10 statutory categoriesHHS Bulletin Updating EHBs ACA 1302(b)(4)(G)and(H)requires regular review and updating of EHB by Secretary Seeking comment on how to assess enrollee difficulties with acces
9、s due to coverage or cost,changes in medical evidence,or market changes.HHS assumes the“substantially equal”standard for health plans and their annual update of benefits will reflect improvements in the quality and practice of medicine.Planning to propose a process for evaluating benchmark processKe
10、y Concerns Lack of a Federal Minimum Standard ACA directs Secretary to define,review,and update EHB package State and insurer flexibility will result in varying packages across country States should have flexibility to go above a federal floor,but not below No insurer flexibility under any circumsta
11、nces ACA intent is to ensure comprehensive and seamless coverageKey Concerns Minimizing Harm of Benchmark Framework Benchmarks should be subject to minimum national floor of coverage Look to Medicaid program for better benchmark options Also promotes seamless coverage for folks transitioning between
12、 Medicaid and Exchange Eliminate small group product option in current benchmark scheme No benefit substitutionKey Concerns EHB should be:Typical Employer Plan PLUS Ten Statutory Categories Ten categories intentionally address gaps in existing coverage Congressional intent to transform health covera
13、ge and delivery systems Investment in promoting health over long term,not just short-term savingsKey Concerns State Mandates States may choose benchmarks that dont include important mandated services Because states pay for services they require beyond the EHB,incentive for States to phase out mandat
14、es Strongly encourage process for reviewing and including evidence-based or otherwise valuable mandated benefitsKey Concerns Harmful Utilization Management Practices Health plans may use restrictive or discriminatory service limits,medical necessity definitions,and other utilization management polic
15、ies to disrupt consumer access to necessary care Need strong standards for medical necessity and other protections Plans must ensure linguistically and culturally appropriate services and deliveryKey Concerns Non-discrimination ACA 1557 and EHB provision(1302)prohibit discrimination Excessive flexib
16、ility causing discriminatory adverse selection must be eliminated Regular Review and Updating of EHB Package Must ensure transparent process with public input to evaluate and update EHB Should include review to ensure certain populations are not harmed by EHB standardThank you!Jina Dhillon,dhillonhealthlaw.org National Health Law Program101 E.Weaver StreetCarrboro,NC(919)968-6308www.healthlaw.org
