1. Essential Health Benefits Michelle Lilienfeld January 23, 2015

2. Overview Background: process resulting in current EHB standard EHB Basics: current EHB rules EHB Update: policy issues to address HHS’ proposed changes NHeLP recommendations 2

3. Background: Ten EHB statutory categories of benefits ambulatory patient services, emergency services, hospitalization, maternity & newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, lab services, preventive and wellness services and chronic disease management and pediatric services including oral and vision care 3

4. Background: Defining the EHBs Per the ACA: Authority to define the EHBs delegated to the Secretary of HHS EHBs must be equal to the scope of benefits provided under a typical employer plan The Secretary must also ensure the EHBs 1)reflect balance among categories, 2)account for diverse health needs across populations, and 3)not discriminate against individuals because of age, disability or expected length of life 4

5. Background: HHS guidance leading to current EHB rules EHB Bulletin (Dec. 2011): HHS announces its intended regulatory approach EHB FAQs (Feb. 2012): further clarification EHB proposed rule (Nov. 2012): 30-day comment period EHB final rule (Feb. 2013): almost identical to proposed rule 5

6. EHB Basics: What are the current EHB rules? 6 BenchmarkingSupplementingSubstitutionState Mandates

7. EHB Basics: Benchmarking Each state uses a base-benchmark plan as a reference plan to define EHBs in the state States can select their EHB base-benchmark plan from among ten options: 3 largest federal employee plans, 3 largest state employee plans in the state, 3 largest small group plans in the state, or the largest commercial HMO operating in the state 7

8. EHB Basics: Benchmarking cont’d States not selecting a benchmark plan get the default benchmark—the largest small group plan in the state EHB Final Rule, Appendix A: List of the EHB base- benchmark plans in the states and D.C. Additional information regarding benefits covered: CCIIO charts: http://www.cms.gov/CCIIO/Resources/Data- Resources/ehb.html http://www.cms.gov/CCIIO/Resources/Data- Resources/ehb.html NAIC website: http://www.naic.org/index_health_reform_section.htm http://www.naic.org/index_health_reform_section.htm 8

9. EHB Basics: Supplementing EHB base-benchmark plans that do not include items or services in one of the 10 EHB statutory categories must be supplemented by adding that entire category from any other EHB base-benchmark option Supplementing only occurs when the base-benchmark plan does not cover any items/services in one of the 10 EHB statutory categories A plan with minimal coverage does not get supplemented NOTE: There are special supplementing methods for pediatric oral and vision care 9

10. EHB Basics: Substitution Issuers may substitute benefits that are actuarially equivalent to the benefits replaced, as long as they are within the same benefit category This does not apply to Rx drugs Subject to non-discrimination requirements States have the option to adopt more stringent standards that limit or prohibit this type of substitution For example: CA generally prohibits issuers from substituting benefits 10

11. EHB Basics: State Mandates For 2014 and 2015 state benefit mandates enacted on or before 12/31/11 (even if not effective until a later date) are not considered additional to the EHBs, so states do not have to defray the cost of these benefits State mandates policy unclear for 2016 and beyond Some states concerned with potential costs have passed new mandates but indicated they do not apply to plans required to provide the EHBs 11

12. EHB Update Opportunity for advocates and stakeholders to provide feedback and recommendations to improve the current EHB standard In the next few slides: EHB rule = Current EHB standard Proposed update(s) = HHS’ proposed updates from the Notice of Benefit and Payment Parameters for 2016 Proposed Rule NHeLP = Recommendations made in comments to HHS and issues we are monitoring 12

13. EHB Update: Benchmarking EHB rule: No federal standards Benchmarking approach with lots of state and issuer flexibility Proposed update: HHS proposes to allow states to select a new base- benchmark plan for the 2017 plan year NHeLP: Continue to push for firm and comprehensive federal standard HHS should establish a minimum standard definition for 2- 3 EHB benefit categories for the 2016 plan year, while working towards federal minimum definitions in the other EHB categories by a set date 13

14. EHB Update: Pediatric Services EHB rule: General EHB benchmarking applies to pediatric services, except for pediatric vision and oral care Proposed update: Pediatric services provided until the end of the plan year in which the enrollee turns 19 years old NHeLP: Raise age limit for pediatric services to age 21 Need different benchmark for children: EPSDT or CHIP Studies have shown the current benchmarking system is not working for pediatric services  Wakely Consulting Group Report (July 2014) http://www.wakely.com/wp-content/uploads/2014/07/FINAL- CHIP-vs-QHP-Cost-Sharing-and-Benefits-Comparison- First-Focus-July-2014-.pdf http://www.wakely.com/wp-content/uploads/2014/07/FINAL- CHIP-vs-QHP-Cost-Sharing-and-Benefits-Comparison- First-Focus-July-2014-.pdf 14

15. EHB Update: Habilitative Services EHB rule: State and issuer flexibility in defining the benefit Proposed updates: Uniform definition of habilitative services Yet it appears states can still define the benefit as long as the definition is non-discriminatory Removes issuer flexibility to define the benefit NHeLP: Require that all states adopt the proposed uniform definition as a minimum standard (unless the state’s definition is more comprehensive) 15

16. EHB Update: Rx Drugs EHB rule: United States Pharmacopeia (USP) standard Proposed updates: Replace USP standard with pharmacy and therapeutics (P&T) committee, American Hospital Formulary Service (AHFS) classification system, or combination of both New requirements for:  Rx drug exception process  Posting Rx drug formularies online  Access to Rx drugs through in-network retail pharmacies NHeLP: See our Rx drug comments at pgs. 20-24: http://www.healthlaw.org/publications/browse-all-publications/nhelp- comments-notice-of-benefit-and-payment-parameters 16

17. EHB Update: Non-Discrimination EHB rule: No guidance regarding what HHS considers discrimination Proposed update: Examples provided in the preamble of discriminatory practices by health plans and a reminder to plans of the ACA’s non- discrimination requirements, but there is no actual language in the regulation NHeLP: Urged rigorous monitoring and enforcement of the ACA’s non- discrimination provisions  NHeLP and The AIDS Institute pending HIV/AIDS discrimination complaint with Office for Civil Rights Need clearer guidance and coordination among agencies 17

18. QUESTIONS Michelle Lilienfeld Senior Attorney National Health Law Program (310) 736-1648 lilienfeld@healthlaw.org 18

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