Activity Afoot on Essential Health Benefits

Did you know states need to select their Essential Health Benefits (EHB) benchmark plan for 2017 in just a few weeks? If not, you could be forgiven for missing this one. There’s plenty going on to capture your attention – the wait for the Supreme Court to weigh in on premium tax credits in federally facilitated marketplaces, health insurers filing their proposed rates for 2016, and more good news on Medicaid expansion states. But work is underway to select an EHB benchmark and advocates have a small window now to offer input. To get caught up, don’t look for written dates and deadlines from CCIIO; they don’t exist. Instead, read on.

In an update provided to state regulators at the NAIC Spring meeting, CCIIO officials announced a June 1, 2015 deadline for states to select an EHB benchmark for small employer and individual coverage available in 2017. The process is the same as the one states used for selecting EHB benchmarks for use in plan years 2014-2016. States can select from among 10 plans available to state residents: the 3 small employer plans with the greatest enrollment, 3 federal employee plans with the greatest enrollment, the non-Medicaid HMO with the largest enrollment, and the 3 largest state employee plans by enrollment. If a state does not choose a benchmark plan, the default plan is the small employer plan with the largest enrollment.

Since this announcement was made, CCIIO published a list of the top 3 small employer plans by enrollment in each state. The list also includes the top 3 federal employee plans and the Federal Employees Dental and Vision Program (FEDVIP), which states can use to supplement their benchmark plans for pediatric vision and dental coverage. The first task for states was to review that list and provide corrections to CCIIO by April 30th and to identify the other benchmark options for the state: the top 3 state employee plans and the largest non-Medicaid commercial HMO.

In addition to selecting an EHB plan, states have a number of areas in which they can strengthen the benefit standard for consumers, and children in particular. For example, states can:

  • Prohibit substitution of benefits within categories,
  • Adopt a more comprehensive definition of habilitative services,
  • Adopt a strong standard for pediatric vision and dental services,
  • Extend pediatric services to children up to age 21, and
  • Set strong standards for prescription drug benefits.

The National Health Law Program has done a paper outlining advocacy opportunities.

Once state selections are made – or default plans identified for states that don’t choose a plan – CCIIO will publish state selections for public comment. But advocates shouldn’t wait for that public comment period.

Advocates wishing to weigh in on their state process have a few immediate advocacy options:

  • Ask your state officials (likely the Department of Insurance but possibly the marketplace or governor’s staff) if they have provided updates to CCIIO’s posted list of plans. CCIIO is expected to publish an updated list that includes state feedback.
  • Ask your state officials if they have or are planning to request an extension of the June 1st deadline for submitting EHB selections. We understand some states have already done so, and extensions have been granted until the end of June.
  • Suggest that there be a public process for stakeholders to review EHB options and provide input on the selection and key design decisions. We know some states have already started a public process, including Oregon and Maryland.

If you’ve noticed that there is little time to provide input into state selections – even with the 30 day extension some states have obtained – don’t give up hope. Advocates can continue to push for changes through legislation or regulation, but keep in mind that plan requirements, including the provision of EHB, must be in place prior to the deadline for plan rate and benefit filings next spring. Once the new benchmark is in use, advocates can work with state regulators to monitor implementation of EHB in order to identify any gaps in coverage or needed improvements, to ensure this ACA requirement delivers on the promise of adequate coverage for consumers enrolled in individual and small employer plans.

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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.