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Dental trade groups, HHS
Dental trade groups are concerned HHS will require that insurers offer pediatric dental coverage without making enrollees buy.
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Delicate balance

Flexibility at issue in essential benefits


By Jessica Zigmond
Posted: January 26, 2013 - 12:01 am ET
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Ahead of HHS' final word on essential health benefits, tension is emerging between provider groups that say giving states and health plans too much flexibility could render the coverage meaningless, and business groups that argue more flexibility is needed to make coverage affordable.

Industry experts expect HHS to release its final regulation on the critical piece of the healthcare reform law this quarter, with one source speculating that could happen in mid-to-late February. It has been a month since the public comment period closed on HHS' proposed rule on the package of services the law requires for plans in the individual and small-group markets starting next year, whether or not the plans are sold in the insurance exchanges established under the law. Now the department must strike a delicate balance in developing a rule that ensures patients have access to the care the law requires, while also making sure the coverage isn't so expensive that no one will buy it.

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A group of business organizations, health plans and provider associations calling itself the Essential Health Benefits Coalition emphasized the rising costs of coverage during a news conference last week staged to highlight its recommendations for the regulation. The coalition, which includes the U.S. Chamber of Commerce, the National Retail Federation and America's Health Insurance Plans, cited two studies by the firm Milliman for the Indiana Exchange and the Ohio Department of Insurance that estimated fulfilling the essential health benefits requirements could increase premiums in the individual market by as much as 20% to 30%.

Survey results released last week underscored the cost concern: More than 54% of U.S. small-business owners reported that healthcare costs are hurting their operating environment “a lot,” according to a January Wells Fargo/Gallup Small Business survey.

The EHB Coalition wants essential health benefits in health plans to look more like private coverage and less like Medicare, said Neil Trautwein, the group's chairman and the National Retail Federation's vice president and employee benefits counsel. Private coverage, he said, can react more quickly when providers call for a particular treatment or when there are advancements in the field.

“Really, the lack of specificity or specific inclusion—service by service—is a strength of private coverage,” Trautwein said. “And we would hope the EHB would maintain and follow that lead.”

And therein lies the tension. Too much flexibility in designing essential health benefits has patient advocates and provider groups worried that patients won't be able to receive the kind of care they need.

“In some way, it may seem like a good idea,” said Julie Allen, government relations director at Drinker Biddle and Reath in Washington. Allen's firm represents the American Dental Association, which submitted a comment letter to HHS asking the department to clarify elements of the pediatric oral benefit. “But the concern is that there will be little or no consistency across state lines,” she said. “Someone could go from good coverage to not-so-good coverage.”

Giving states and health plans too much leeway is also a concern for the nation's hospitals, said Ellen Pryga, a director of policy at the American Hospital Association.

“All of the high degree of variability in benefit design is creeping back in through a whole myriad of decisions,” Pryga said. “Part of the whole point was to bring more consistency to the picture to make sure the benefits people buy have actual value.”

Pryga said health plans have “pretty free rein” to substitute services within the state's benchmark plan as long as those services are actuarially equivalent. The risk is that whole areas of service could be excluded. Pryga cited inpatient rehabilitative services as one example. The essential health benefits provision requires both rehabilitative and habilitative services, but allowing for substitutions within that category means plans can exclude certain types of rehabilitation.

Ian Spatz, a senior adviser at Manatt Health Solutions, said he hasn't seen any surprises as opposing sides attempted to influence the proposed rule for essential health benefits, which HHS released in late November. “It's really what's at the margins that are getting the most attention,” he said, citing pediatric dental and vision care as one of those areas.

In their comment letter to HHS, the ADA and the American Academy of Pediatric Dentistry said an expansion of children's dental coverage could be undermined by “an interpretation of the ACA that requires the pediatric oral benefit to be offered as one of the EHBs but does not necessarily require it to be purchased,” something the two organizations said the department must address in its final rule.

The EHB Coalition, meanwhile, balked at the proposed rule's recommendation that state benchmark plans lacking pediatric oral or vision care be supplemented by adding the entire category of benefits from either the Federal Employee Dental and Vision Insurance Plan or the state's separate Children's Health Insurance Program plan. The group says those plans go beyond benefits in small-group or individual plans and will weaken the goal of keeping coverage affordable for employers and individuals.

To ensure healthcare insurance is meaningful and affordable, coverage must be rooted in evidence-based guidelines, the AHA said in its comments to HHS. And applying such guidelines in the EHB design appears to be an area of common ground between some healthcare providers and business groups. At the EHB Coalition news conference, Dr. Geraldine O'Shea of the American Osteopathic Association (a coalition member) said these guidelines help ensure not only appropriate medicine, but also affordable medicine, as clinical organizations or academies have already determined what provides the lowest risk and best benefit for the patient.

“You want them to have risk analysis that is right for the group,” O'Shea said later in an interview. “As a physician, I know there are age-appropriate treatments that should be followed. There is a reason we give vaccinations to infants.”

Paul Fronstin, director of the health research and education program at the Employee Benefit Research Institute, served as a member of the Institute of Medicine panel that made recommendations to HHS before the department developed its proposed rule. The IOM panel, he said, recommended that everything within the 10 essential health benefit areas be evidence-based by 2016.

“HHS hasn't taken all of our recommendations literally,” Fronstin said. “But they have said they will re-look at this in 2016.”


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