Health benefits advisors are asking federal regulators to think about more than the premiums when they are updating the rules for designing “essential health benefits” packages, or standard major medical insurance benefits packages.
The EHB packages should also include adequate behavioral health, diabetes care, maternity care and telehealth benefits, the advisors are telling the Centers for Medicare & Medicaid Services.
“Behavioral health, preventive care and chronic disease management are not optional,” Melanie Nofziger, the owner of Crown Health Benefits of Carrollton, Texas, wrote in a comment letter to CMS. “They are foundational to health and financial stability. I have seen clients transformed by mental health coverage, catastrophic diagnoses avoided because preventive care caught conditions early and chronic conditions like diabetes managed because the plan covered ongoing care.”
See also: From Baby Boomers to Gen Z: Crafting the perfect employee benefits package
Michael Moro, the owner of Moro Family Insurance in New Berlin, Wisc., asked CMS to consider whether patients have meaningful access to services like mental healthcare, as well as policies that say they have coverage for those services.
“Utilization-management tools (prior authorization, narrow networks, formulary restrictions, therapy limits, medical-necessity criteria) have a legitimate role but should not function as hidden benefit reductions,” Moro wrote. “A plan should not satisfy the letter of EHB while making important care unreasonably hard to obtain. This matters most in prescription drugs, mental health and substance use treatment, rehabilitative and habilitative services, chronic disease management, maternity, pediatric and preventive care.”
Anthony Nefouse, president of Nefouse & Associates of Indianapolis, warned against using large but relatively old plans to create EHBs. Basing the EHB package on an older plan “creates tension with rising medical costs, new therapies and evolving care delivery,” he said.
Older plans are especially likely to lack or skimp on coverage for telehealth services and behavioral health services, Nefouse said.
Mychal Walker, a benefits advisor in Georgia and president of the National Association of Benefits and Insurance Professionals, wrote on behalf of NABIP that CMS should consider new technologies, new health care delivery arrangements and the increase in behavioral health services needs when reviewing EHB rules.
“Evaluate affordability as a core component of access, while recognizing that affordability is not measured by premiums alone,” Walker said. “A lower-premium plan may still be unaffordable if deductibles, co-payments, co-insurance, prescription drug costs, out-of-pocket maximums or uncovered services leave consumers unable to afford care when they need it.”
The benefits professionals are some of the 357 individuals and organizations that have written to CMS in response to a CMS request for information about what it should keep in mind if and when it tries to revise the existing EHB package rules.
The comment period ended July 15.
At press time, CMS had posted 179 of the comments received.
Benefits advisors aim to educate legislators on behavioral health
What it means: Benefits advisors often spend a great deal of time educating clients about how to weigh coverage premiums against the out-of-pocket costs.
Now, benefits advisors are trying to educate policymakers in Washington about the importance of looking at more than the monthly premiums.
The Affordable Care Act essential health benefits package: The lawmakers who wrote the Affordable Care Act and the regulators who implemented it used the EHB to form the foundation of the ACA health insurance exchange system, the employer coverage offer mandates and the ACA premium tax credit subsidy program, by creating a standard definition of “minimum essential coverage,” or solid major medical coverage.
An EHB package includes 10 types of benefits. Each state is supposed to design an EHB package based on a “typical employer plan” or similar benchmark plan in its state.
Major medical plans sold or changed significantly since 2010, when the EHB rules became federal law, are supposed to provide unlimited annual and lifetime coverage for EHB services.
Patients and providers often complain that the EHB package excludes important services.
Insurers, employers and plans say some states push up the cost of major medical coverage to unsustainable levels by using the EHB package to require coverage for very expensive services, such as in-vitro fertilization services.
Behavioral health parity: The ACA, other federal laws and ACA regulations require issuers of individual and fully insured small-group health insurance to provide comparable coverage for mental health care, substance use disorder care and other types of health care.
Self-insured plans and large fully insured plans can choose whether to cover behavioral health care, but if they cover it, they must cover it the same way they cover other EHB components.
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