Group Makes Recommendations for Essential Health Benefits

Other considerations recommended include: 

• Apply cost and medical effectiveness considerations to all benefits, including state mandates. Development of the EHB package should incorporate evaluations of benefits, including state benefit mandates, from both a cost and medical effectiveness perspective. The Coalition recommends that in order to ensure affordability, HHS encourage states to undertake a review of their most costly benefit mandates, using the method described by the IOM in its recommendations to HHS on defining EHBs, and exclude state-mandated benefits that lack a strong evidence-base after the transition period (2014 to 2015). 

• Ensure affordability by allowing health plans to make a “good faith” determination of whether or not a benefit included in the benchmark is essential for purposes of applying annual limits. The February “Frequently Asked Questions (FAQ)” document indicates that HHS will prohibit annual dollar limits on any benefit, including state-mandated benefits, in the benchmark, although the FAQ indicates that health plans would be permitted to impose non-dollar limits that are at least actuarially equivalent to the annual dollar limits. To ensure affordable coverage, the Coalition urges HHS to permit health plans to make a good faith determination of whether the benefits offered in the state benchmark, including state-mandated benefits, are essential (i.e., fall within the 10 statutorily-required essential health benefit categories). If a health plan determines in good faith that a benefit is not essential (does not fall into one of the 10 categories), the health plan may apply annual dollar limits on that benefit. If a health plan determines that a benefit is essential, the health plan may not apply annual dollar limits on that benefit. 

• Permit flexibility in determining actuarially equivalent benefits. The EHB Bulletin provides that health plans will be required to offer benefits that are “substantially equal” to the benefits in the benchmark plan. To ensure affordable coverage, the Coalition urges HHS to adopt rules that allow the maximum amount of flexibility in determining reasonable substitutions that have an actuarially equivalent value to the benefits in the benchmark plan.