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1、Jina DhillonJD,MPH,“Securing Health Rights for Those in Need”,Essential Health Benefits,Roadmap,BackgroundOverview of HHS BulletinKey concerns and advocacy response,Background,Secretary must define essential health benefits(EHB)packageEHB must be equivalent to typical employer coverageEHB must cover
2、 ten categories of services ACA 1302,Background,Ten Categories,Ambulatory patient servicesEmergency servicesHospitalizationMaternity and newborn careMental health,substance abuse,behavioral healthPrescription drugsRehabilitative&habilitative services&devicesLaboratory ServicesPreventive and wellness
3、 services,chronic disease managementPediatric,including oral&vision careACA 1302(b)(1),HHS Bulletin,Intended Regulatory ApproachEHB 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 largest small
4、 group insurance products*;Any of largest State employee health benefit plans;Any of largest three national FEHBP plan options;ORLargest insured commercial non-Medicaid HMO,*If State does not select a benchmark,this is the default.,HHS Bulletin,Benchmark Approach and 10 CategoriesBenchmark approach
5、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 categories,as
6、 identified by HHS,are habilitative services and pediatric oral and vision services.,HHS Bulletin,States cover costs of benefits beyond EHBACA requires that State must pay for mandated benefits in excess of EHBFor 2014 and 2015,if State selects benchmark subject to mandates,those mandates are part o
7、f the States EHB package and State would not have to defray those costs.,HHS Bulletin,Benefit Design FlexibilityHealth plans given flexibility to offer benefits that are“substantially equal”to benefits of the benchmark plan selected by State,as modified to meet 10 categoriesHealth plans can adjust b
8、enefits(both specific services and/or quantitative limits)so long as they continue to cover all 10 statutory categories,HHS Bulletin,Updating EHBsACA 1302(b)(4)(G)and(H)requires regular review and updating of EHB by SecretarySeeking comment on how to assess enrollee difficulties with access due to c
9、overage 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 process,Key Concern
10、s,Lack of a Federal Minimum StandardACA directs Secretary to define,review,and update EHB package State and insurer flexibility will result in varying packages across countryStates should have flexibility to go above a federal floor,but not belowNo insurer flexibility under any circumstancesACA inte
11、nt is to ensure comprehensive and seamless coverage,Key Concerns,Minimizing Harm of Benchmark FrameworkBenchmarks should be subject to minimum national floor of coverageLook to Medicaid program for better benchmark optionsAlso promotes seamless coverage for folks transitioning between Medicaid and E
12、xchangeEliminate small group product option in current benchmark schemeNo benefit substitution,Key Concerns,EHB should be:Typical Employer Plan PLUS Ten Statutory CategoriesTen categories intentionally address gaps in existing coverageCongressional intent to transform health coverage and delivery sy
13、stemsInvestment in promoting health over long term,not just short-term savings,Key Concerns,State MandatesStates may choose benchmarks that dont include important mandated servicesBecause states pay for services they require beyond the EHB,incentive for States to phase out mandatesStrongly encourage
14、 process for reviewing and including evidence-based or otherwise valuable mandated benefits,Key Concerns,Harmful Utilization Management PracticesHealth plans may use restrictive or discriminatory service limits,medical necessity definitions,and other utilization management policies to disrupt consum
15、er access to necessary careNeed strong standards for medical necessity and other protectionsPlans must ensure linguistically and culturally appropriate services and delivery,Key Concerns,Non-discriminationACA 1557 and EHB provision(1302)prohibit discriminationExcessive flexibility causing discrimina
16、tory adverse selection must be eliminatedRegular Review and Updating of EHB PackageMust ensure transparent process with public input to evaluate and update EHBShould include review to ensure certain populations are not harmed by EHB standard,Thank you!,Jina Dhillon,dhillonhealthlaw.org National Health Law Program101 E.Weaver StreetCarrboro,NC(919)968-6308www.healthlaw.org,
