The ATS recently submitted comments on health benefits and other patient protections in response to the Department of Health and Human Service’s recently proposed rule to permit state flexibility in designing essential health benefits (EHB) and other rules for the individual and small business health insurance markets.
Specifically, the rule proposes to permit states to select other state EHB benchmark plans, or new ones from among a state’s three largest small group plans. This means that states could select an EHB plan from another state that has more limited benefits and imposes more cost-sharing on patients. The Department is further proposing to permit states to allow insurers to shift benefit value across the 10 EHB categories, with the exception of the prescription drugs category.
In its comments, the ATS wrote, “Permitting such variation in covered benefits, despite mandated categories of EHBs, will promote highly varied and potentially inadequate benchmark standards in states that may not include the full range of health care services that people with chronic respiratory and critical illnesses and sleep disorders need.” Concerning the proposal to allow benefit value shifts across EHB categories, the ATS stated, “The shifting of benefit values across EHB benefit categories could leave patients with chronic respiratory conditions such as COPD, who need comprehensive coverage across all EHB categories, to have unexpected, significant gaps in their insurance coverage and be left with exorbitant out-of-pocket costs for needed treatments, forcing some people to forgo needed care.”
In addition to potentially narrowing EHB benefit packages in some states and increasing costs for certain health care services and treatments, an end result of these proposals could be more adverse selection in state insurance markets that could extend more broadly across the U.S., destabilizing all insurance markets. Such a situation could ultimately leave people with chronic conditions unable to afford health insurance coverage at all, which, the ATS states in its comments, is unacceptable.
The rule’s other proposals including transferring authority for insurance network adequacy standards and oversight from the Department of Health and Human Services to states and permitting state flexibility on insurance plan medical loss ratio’s (MLR). In its comments, the ATS urged the Administration to ensure appropriate network adequacy, particularly for people with chronic conditions who require specialty care, and to maintain the current MLR’s to ensure consumer value in insurance coverage.
