Experts suggest priorities for essential benefits

Ensuring transparency in benefit design and paying close attention to benefit administration should be among the top priorities of healthcare advocates working on the development of essential health benefits packages, a panel of experts said in Washington.

Essential health benefits were the topic of discussion at the National Forum on the Future of Healthcare, an event hosted by the American Cancer Society’s Cancer Action Network. Following a discussion about the Essential Health Benefits Bulletin that HHS released in December, an audience member asked the panel—which included two current state insurance regulators—what they thought the top priorities will be for insurers in the regulatory process.

“I think you guys should pay attention to benefit administration,” said Rhode Island Health Insurance Commissioner Christopher Koller, referring to healthcare advocates working on this issue. “I think that having in place really consistent, defensible processes for determining medical necessity and for handling consumer appeals is your greatest opportunity for ensuring fair and consistent decision making,” he continued. “I think if health plans know that they’re accountable through that process, and there is a really solid appeals process they can take, it reduces the outlier practices that drive you crazy.”

Meanwhile, Sandy Praeger, the Kansas Insurance Commissioner (who succeeded HHS Secretary Kathleen Sebelius in that role), said it will be very important to make sure that the terms are clear in benefit design.

“I think the benefit design is the key,” Praeger said, “And then looking at that transparency in terms of language and what’s on that front-page document that is supposed to so very appropriately and completely identify the benefits that are included and what the limitations might be.”

And Joel Ario, managing director at Manatt Health Solutions and the former director of HHS’ Office of Insurance Exchanges, offered insight into how insurers think about this process: “Insurers often say to me: ‘I don't care so much how that benefit is defined; I care about how I can manage it, because if I can manage it however I want to, it doesn't really matter what it says.’ ”

“That’s a clue to something to be thinking about there,” he said.