Flexibility for employers, a minimum federal compliance standard for states, and a clear definition of “medical necessity” were among the essential health benefit recommendations that provider groups, business associations and health plans sent to HHS.
Health benefits feedback
Suggestions to HHS include flexibility, clarity
The suggestions came as the initial comment period ended last week on the essential health benefits “bulletin” that HHS released in December to generate feedback from those who have a stake in the benefits that health plans must include in 2014. HHS—which will still accept suggestions—received just more than 7,000 comments.
HHS said the approach was intended to give states more flexibility in implementing provisions of the Patient Protection and Affordable Care Act. The law requires that health plans offered in the individual and small group markets—both inside and outside of the insurance exchanges—offer a package of services known as essential health benefits. Those benefits must include items and services that fall into 10 categories, including ambulatory care, hospitalization, emergency services, mental health, and preventive and wellness services.
HHS proposed that each state be allowed to model its essential benefit package on the largest HMO plan offering its commercial market or one of the three largest small group plans, state employee health plans or federal employee health plan options.
In a six-page letter to CMS acting Administrator and COO Marilyn Tavenner, the Federation of American Hospitals strongly encouraged HHS to follow the bulletin with a formal rulemaking process. The correspondence from Chip Kahn, FAH president and CEO, said HHS should define “medical necessity” because the term will be used in an array of state insurance exchange products. The FAH also favors an approach that would create a standard, national essential health benefits package that would minimize variability in states and regions, and create a consistent insurance product.
Kahn said “unbridled state discretion to set their EHBs packages seems fraught with peril, and in many states could present a ‘race to the bottom’ scenario that harms consumers and providers.” Meanwhile, the Essential Health Benefits Coalition—an association composed of large and small employers, pharmacy benefit managers and health plans in each state—said an essential health benefits package should evaluate benefits, including state benefit mandates, from both a cost and a medical effectiveness perspective. And only current benefits in effect as of March 1, 2012, should be considered for the so-called benchmark essential health benefits package, as opposed to allowing new state benefit mandates to be added retroactively, the group said.
The Children’s Hospital Association (formerly known as the National Association of Children’s Hospitals) highlighted concerns that include a lack of definition for pediatric services in the guidelines, and the selection of benchmark plans that typically don’t include services required for children with disabilities.
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