1. Dania Palanker National Women’s Law Center January 23, 2015 ESSENTIAL HEALTH BENEFITS

2.  Ensuring Plan Compliance  Improving the Essential Health Benefits (EHB)  Prescription Drugs  Maternity Coverage PRESENTATION OUTLINE

3. ENSURING PLAN COMPLIANCE

4.  NWLC analyzed QHP plan documents in 13 states  Based on 2014 plan documents  Some insurance commissioners and plans have corrected compliance problems REVIEWING PLANS FOR COMPLIANCE

5. A plan cannot exclude an enrollee from any EHB category except pediatric services 45 CFR 156.115(a)(2) Problematic Plan Language: “Exclusions Under this Policy… Maternity expenses for Dependents unless there are life threatening complications.” EXCLUDING DEPENDENTS FROM MATERNITY CARE

6. Issuers may not impose benefit specific waiting periods in EHB CMS FAQ May 16, 2014 Problematic plan design examples:  Transplant coverage limited to enrollees who had been enrolled the previous year  90 day waiting period on transplants EXCLUDING TRANSPLANT SERVICES FOR NEW ENROLLEES

7. Plans providing EHB must comply with preventive services requirement 45 CFR 156.115 Unallowable plan designs:  Denying coverage for OTC contraceptive methods with a prescription  Excluding coverage of breast pumps  Imposing cost-sharing on all brand-name contraceptives PREVENTIVE SERVICES

8.  ACA Prohibits discrimination on the basis of race, color, national origin, sex, age, disability, gender identity, sexual orientation and sex stereotypes ACA Section 1557  An issuer does not provide EHB if the benefit design discriminates based on age, expected length of life, disability, medical dependency, quality of life, or other health conditions 45 CFR 156.125 PROHIBITIONS ON DISCRIMINATION

9.  Maternity care outside of service area  Transition related care  Services for treatment of intractable and chronic pain DISCRIMINATORY BENEFIT EXCLUSIONS

10. IMPROVING THE ESSENTIAL HEALTH BENEFITS

11. How can we improve prescription drug coverage?  Use a categorization system created for EHB  Ensure plans cover enough drugs in each category or class  Require a consumer friendly exceptions process  Prevent tiering and cost sharing from undermining access PRESCRIPTION DRUGS

12.  Only 12% of plans sold on individual market covered maternity in 2012 NWLC, Turning to Fairness  All new plans in individual and small group market now cover maternity  But, a lack of definition or standards for maternity care in regulations MATERNITY COVERAGE

13. Dania Palanker Senior Counsel National Women’s Law Center DPalanker@NWLC.org THANK YOU!