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Proposed EHB Rule Draws Few Comments

 |  By Margaret@example.com  
   July 09, 2012

The latest effort by the Department of Health and Human Services to establish requirements for essential health benefits drew fewer than 30 comments from interested parties during the proposed rule's 30-day comment period, which ended July 4.

The Patient Protection and Affordable Care Act requires HHS to define EHBs. These are 10 categories of service that must be offered beginning in 2014 by health insurance exchanges, as well as individual and small group health insurance policies.

According to the proposed rule, HHS wants each state to use the small group market plan and product with the largest enrollment as the default benchmark plan if a state doesn't select its own benchmark plan.

It would tag two familiar organizations, the National Committee for Quality Assurance and the non-profit URAC, as the interim accrediting organizations for health plans that want to be part of the state health insurance exchanges. The NCQA and URAC are already responsible for most health plan accreditations.

In soliciting comments, HHS asked what other data elements might be helpful to collect and requested input on whether closed block products or association products should play a role in defining a benchmark plan.

Public comments touched on several common themes: allowing each state to identify EHB will lead to a patchwork of benefits, the lack of information available on the limits in potential benchmark plans that could impede access to EHB, arbitrary limits will be used to restrict care, and the need for detailed information on prescription drug coverage.

Here are some of the comments posted on regulations.gov:

AARP, an interest group with 40 million members, is concerned that the state-by-state approach to identifying EHB will lead to "significant variability" in benefits among states. It wants data to be collected that includes the percentage of available drug products on a formulary, as well as the drugs subject to prior authorization, step therapy, or quantity limits. While it agrees with the decision to allow plans that meet NCQA or URAC standards to participate, the AARP wants assurances that the two organizations are "equally rigorous" to prevent health plans from venue shopping "for the easiest path to accreditation. To our knowledge, the processes of NCQA and URAC are not comparable."

The group also is concerned about making network adequacy a part of the accreditation process. AARP views that as a regulatory function. "No plan should be allowed to participate in the exchange with an inadequate network, regardless of how well it does on other aspects of accreditation."

The Cancer Action Network, the advocacy arm of the American Cancer Society, argues that "arbitrary and unreasonable limits (in [potential benchmark plans) could be used to restrict needed care" and may be inconsistent with healthcare reform's "clear intention to guarantee that at least the 10 benefit categories are covered." The group is concerned that the medical benefits template for individual family plans included a question about diabetes wellness plans. "We want to ensure that wellness programs, which are not actually benefits, are not included in the EHB."

The network recommends that each health plan submit its definition of medical necessity, which it says can vary widely among plans.

The American Federation of State, County & Municipal Employees, which represents 1.6 million members and retirees, wants HHS to collect data on rider policies made available by a health plan. "High enrollment in a plan can be attributed, at least in part, to the availability of rider policies" and is information HHS needs to develop policy that reflects the ACA requirement that EHB reflect a typical employer plan.

The Federation of American Hospitals which represents more than 1,000 investor-owned or managed community hospitals and health systems, wants the Centers for Medicare & Medicaid Services to clarify "the specific language related to measures that are developed or adopted by a voluntary consensus standards setting body." FAH notes that the National Quality Forum is the designated consensus-based entity under contract with HHS to endorse clinical quality measures and wants to specify that measure sets used for quality health plan accreditation include measures that are endorsed by the NQF.

Cigna, a provider of health insurance and related services, wants a consistent definition of habilitative services to be applied across all health plans. "We do not support the option of allowing plans to decide which habilitative services to cover." Cigna proposes that habilitative services be "covered in parity with rehabilitative services." It want coverage for both to be limited to care with "quantifiable, measureable, and attainable treatment goals."

It doesn't support the inclusion of block or association products in defining benchmark plans. "Closed blocks are intended to be retired and no longer offered to new purchasers."

Bayer Healthcare, a specialty pharmaceutical and medical device company, expressed concern that some state policymakers could try to limit coverage for contraceptives by selecting benchmark plans that offer less favorable coverage. Bayer wants health plans to be required to provide information about how contraceptive drugs are covered under preventive services benefits, including any required cost sharing.

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Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
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