Transcript Presentation Title

Essential Health Benefits
Michelle Lilienfeld
January 23, 2015
Overview
• Background: process resulting in
current EHB standard
• EHB Basics: current EHB rules
• EHB Update:
• policy issues to address
• HHS’ proposed changes
• NHeLP recommendations
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Background: Ten EHB statutory
categories of benefits
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ambulatory patient services,
emergency services,
hospitalization,
maternity & newborn care,
mental health and substance use disorder
services, including behavioral health treatment,
prescription drugs,
rehabilitative and habilitative services and devices,
lab services,
preventive and wellness services and chronic disease
management and
pediatric services including oral and vision care
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Background: Defining the EHBs
• Per the ACA:
• Authority to define the EHBs delegated to the
Secretary of HHS
• EHBs must be equal to the scope of benefits provided
under a typical employer plan
• The Secretary must also ensure the EHBs
1) reflect balance among categories,
2) account for diverse health needs across populations, and
3) not discriminate against individuals because of age,
disability or expected length of life
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Background: HHS guidance leading
to current EHB rules
• EHB Bulletin (Dec. 2011): HHS announces
its intended regulatory approach
• EHB FAQs (Feb. 2012): further clarification
• EHB proposed rule (Nov. 2012): 30-day
comment period
• EHB final rule (Feb. 2013): almost identical
to proposed rule
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EHB Basics: What are the current
EHB rules?
Benchmarking
Supplementing
Substitution
State Mandates
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EHB Basics: Benchmarking
• Each state uses a base-benchmark plan as a
reference plan to define EHBs in the state
• States can select their EHB base-benchmark
plan from among ten options:
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3 largest federal employee plans,
3 largest state employee plans in the state,
3 largest small group plans in the state, or
the largest commercial HMO operating in the
state
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EHB Basics: Benchmarking cont’d
• States not selecting a benchmark plan get the
default benchmark—the largest small group plan
in the state
• EHB Final Rule, Appendix A: List of the EHB basebenchmark plans in the states and D.C.
• Additional information regarding benefits covered:
• CCIIO charts:
http://www.cms.gov/CCIIO/Resources/DataResources/ehb.html
• NAIC website:
http://www.naic.org/index_health_reform_section.htm
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EHB Basics: Supplementing
• EHB base-benchmark plans that do not include items or
services in one of the 10 EHB statutory categories must
be supplemented by adding that entire category from
any other EHB base-benchmark option
• Supplementing only occurs when the base-benchmark
plan does not cover any items/services in one of the 10
EHB statutory categories
• A plan with minimal coverage does not get
supplemented
• NOTE: There are special supplementing methods for
pediatric oral and vision care
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EHB Basics: Substitution
• Issuers may substitute benefits that are actuarially
equivalent to the benefits replaced, as long as
they are within the same benefit category
• This does not apply to Rx drugs
• Subject to non-discrimination requirements
• States have the option to adopt more stringent
standards that limit or prohibit this type of
substitution
• For example: CA generally prohibits issuers from
substituting benefits
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EHB Basics: State Mandates
• For 2014 and 2015 state benefit mandates
enacted on or before 12/31/11 (even if not
effective until a later date) are not considered
additional to the EHBs, so states do not have to
defray the cost of these benefits
• State mandates policy unclear for 2016 and
beyond
• Some states concerned with potential costs have
passed new mandates but indicated they do not
apply to plans required to provide the EHBs
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EHB Update
• Opportunity for advocates and stakeholders to
provide feedback and recommendations to
improve the current EHB standard
• In the next few slides:
• EHB rule = Current EHB standard
• Proposed update(s) = HHS’ proposed updates
from the Notice of Benefit and Payment
Parameters for 2016 Proposed Rule
• NHeLP = Recommendations made in comments
to HHS and issues we are monitoring
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EHB Update: Benchmarking
• EHB rule:
• No federal standards
• Benchmarking approach with lots of state and issuer flexibility
• Proposed update:
• HHS proposes to allow states to select a new basebenchmark plan for the 2017 plan year
• NHeLP:
• Continue to push for firm and comprehensive federal standard
• HHS should establish a minimum standard definition for
2- 3 EHB benefit categories for the 2016 plan year, while
working towards federal minimum definitions in the other
EHB categories by a set date
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EHB Update: Pediatric Services
• EHB rule:
• General EHB benchmarking applies to pediatric services,
except for pediatric vision and oral care
• Proposed update:
• Pediatric services provided until the end of the plan year in
which the enrollee turns 19 years old
• NHeLP:
• Raise age limit for pediatric services to age 21
• Need different benchmark for children: EPSDT or CHIP
• Studies have shown the current benchmarking system is not
working for pediatric services
 Wakely Consulting Group Report (July 2014)
http://www.wakely.com/wp-content/uploads/2014/07/FINALCHIP-vs-QHP-Cost-Sharing-and-Benefits-ComparisonFirst-Focus-July-2014-.pdf
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EHB Update: Habilitative Services
• EHB rule:
• State and issuer flexibility in defining the benefit
• Proposed updates:
• Uniform definition of habilitative services
• Yet it appears states can still define the benefit as long as
the definition is non-discriminatory
• Removes issuer flexibility to define the benefit
• NHeLP:
• Require that all states adopt the proposed uniform
definition as a minimum standard (unless the state’s
definition is more comprehensive)
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EHB Update: Rx Drugs
• EHB rule:
• United States Pharmacopeia (USP) standard
• Proposed updates:
• Replace USP standard with pharmacy and therapeutics (P&T)
committee, American Hospital Formulary Service (AHFS)
classification system, or combination of both
• New requirements for:
 Rx drug exception process
 Posting Rx drug formularies online
 Access to Rx drugs through in-network retail pharmacies
• NHeLP: See our Rx drug comments at pgs. 20-24:
http://www.healthlaw.org/publications/browse-all-publications/nhelpcomments-notice-of-benefit-and-payment-parameters
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EHB Update: Non-Discrimination
• EHB rule:
• No guidance regarding what HHS considers discrimination
• Proposed update:
• Examples provided in the preamble of discriminatory practices
by health plans and a reminder to plans of the ACA’s nondiscrimination requirements, but there is no actual language in
the regulation
• NHeLP:
• Urged rigorous monitoring and enforcement of the ACA’s nondiscrimination provisions
 NHeLP and The AIDS Institute pending HIV/AIDS
discrimination complaint with Office for Civil Rights
• Need clearer guidance and coordination among agencies
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QUESTIONS
Michelle Lilienfeld
Senior Attorney
National Health Law Program
(310) 736-1648
[email protected]
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THANK YOU
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