Protect Ohio Consumers with “Essential Health Benefits”

There is still time for the State to act in the best interests of Ohioans

On December 16, 2011, HHS released an Essential Health Benefits Bulletin whose purpose was to “provide information and solicit comments on the regulatory approach that the Department of Health and Human Services (HHS) plans to propose to define essential health benefits under section 1302 of the Affordable Care Act.” Secretary Sebelius stated that this latest announcement will provide states more flexibility in determining Essential Health Benefits.

Comments on the Bulletin are due on January 31, 2012.

The Affordable Care Act (ACA) makes a number of changes to private health insurance plans. One important protection is the establishment of a package of essential health benefits (EHB).  This protection begins to address the issue of what is covered and how robust of coverage is offered by requiring health insurance policies to cover a minimum set of core benefits within a specific level of coverage with out of pocket expense. According to the ACA, states need to determine their essential benefit benchmark by fall 2012.

Essential Health Benefits (EHBs) comprise of the minimum level of coverage that must be offered by new policies sold in the individual and small group markets in 2014, as well as Medicaid benchmark or benchmark equivalent coverage (i.e., coverage that has historically been less generous than traditional Medicaid and that will be available to many newly eligible individuals in 2014) through the state-based health insurance exchanges.

These benefits include classes of services, benefits covered, the level of financial protection against deductibles and cost-sharing protections. The ACA defines essential health benefits by the following categories:

• Ambulatory patient services (including doctor visits and outpatient care);
• Emergency services;
• Hospitalization;
• Maternity and newborn care;
• Mental health and substance use disorder services, including behavioral health treatment;
• Prescription drugs;
• Rehabilitative and habilitative services and devices;
• Laboratory services;
• Preventive and wellness services;
• Chronic disease management; and
• Pediatric services, including oral and vision care.

The ACA requires that the essential health benefits reflect the same benefits now available to participants in typical employer-sponsored health benefit plans.  HHS so far has consulted the following organizations and individuals for feedback and guidance regarding EHB. They include: the Institute of Medicine (to recommend a process on for defining and updating EHB), the US Department of Labor (to detail benefits typically covered by employers), patients, doctors, nurses, and other interested stakeholders.

As per the December 16, 2011 HHS announcement, instead of creating a federal minimum benefit package, the bulletin allows each state, within certain parameters, to adopt their own definition of the EHB. States must benchmark their EHB to one of four existing health plan options.

HHS will allow states to choose: (1) any of the three largest Federal Employees Health Benefits Program (FEHBP) plans by enrollment, (2) any of the three largest state employee health benefit plans by enrollment, (3) the largest plan by enrollment in any of the three largest small group insurance products offered in the state, or (4) the largest commercial non-Medicaid Health Maintenance Organization (HMO) plan in the state.

As per the ACA, the HHS Secretary has the final responsibility in providing guidance to States to ensure that the EHB meets the needs of consumers/patients, how much discretion allowable to insurers to determine EHB and to revisit the EHB annually.

If Insurance Commissioner Taylor is genuinely interested in protecting Ohio’s citizens, patients, small-businesses (especially the over 1.5 million uninsured Ohioans) she should make the most out the opportunity of being given this State “flexibility” by:

  • Working constructively and effectively with HHS to identify a full list of benchmark options in Ohio and transparently gather Ohio data about these plans and their benefits, and provide this information to the public
  • Proactively utilize available federal dollars and expertise offered to States by HHS to add needed staff who will gather such data for Ohio
  • Engage in public deliberations and organize sturdy transparent consumer and stakeholder input and involvement regarding EHBs
  • And, finally, along with consumer advocates, voice concerns and provide valuable comments at both federal and state levels.

One immediate opportunity for her and others is to submit comments to HHS on the bulletin by January 31, 2012 to essentialhealthbenefits@cms.hhs.gov.