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Essential Health Benefits Bulletin Draws Fire

Margaret Dick Tocknell, for HealthLeaders Media, February 7, 2012

The letter notes that Obama administration "is not required to respond to comments received regarding this bulletin. Publishing a bulletin rather a proposed rule is the antithesis of an open and transparent process."

National Women's Law Center notes that although the Affordable Care Act states that "the scope of the essential health benefits …is equal to the scope of benefits provided under a typical employer plan," other ACA requirements could mean that EHBs are intended to be different from the typical employer plan. "The statute requires categories of coverage, including behavioral health treatment, habilitative services and devices, and pediatric oral and vision (services), that are likely not in the typical employer plan."

The NWLC notes that the ACA requires HHS to take into account "the healthcare needs of diverse segments of the population, including women" and "prohibits discrimination based on the basis of race, color, national origin, sex, age and disability. It may be necessary to expand the scope of benefits in order to adjust for discriminatory practices in the current insurance market. It will not be possible for the EHB to meet these requirements and remain in the scope of the typical employer plan."

The American Hospital Association says the approach to defining EHB fails to reflect "the individual's need for a range of services grounded in evidence-based guidelines. The work of the Institute of Medicine on this subject and the recent issuance of the EHB bulletin suggest that in the struggle to balance affordability with comprehensiveness of health benefits, the recommendations consistently tilt in favor of affordability."

AHA recommends that HHS establish "a universal baseline of benefits, and prevent insurers from picking and choosing the benefits that are covered," adding that affordability of the EHBs "could be governed by the cost sharing amounts among the four levels of qualified health plans." AHA also asks HHS "to clarify that its benchmark plan approach to benefits is "limited to covered services and does not include the plan's underlying decisions regarding actuarial value and cost-sharing."

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