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

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: • • • • 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 base benchmark plans in the states and D.C.

• Additional information regarding benefits covered: • CCIIO charts: http://www.cms.gov/CCIIO/Resources/Data Resources/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 base benchmark 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/FINAL CHIP-vs-QHP-Cost-Sharing-and-Benefits-Comparison First-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/nhelp comments-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 non discrimination requirements, but there is no actual language in the regulation

NHeLP

: • Urged rigorous monitoring and enforcement of the ACA’s non discrimination 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

Washington DC Office 1444 I Street NW, Suite 1105 Washington, DC 20005 ph: (202) 289-7661 fx: (202) 289-7724 [email protected]

Los Angeles Office 3701 Wilshire Blvd, Suite #750 Los Angeles, CA 90010 ph: (310) 204-6010 fx: (213) 368-0774 [email protected]

North Carolina Office 101 East Weaver Street, Suite G-7 Carrboro, NC 27510 ph: (919) 968-6308 fx: (919) 968-8855 [email protected]

www.healthlaw.org