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Rebecca Farley

Director, Policy & Advocacy, National Council for Behavioral Health

“I am Essential” Coalition Urges Improvements to Essential Health Benefits

November 20, 2014 | Health Insurance Exchanges | Comments
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A broad coalition of national groups, including the National Council, has submitted comments to the Center for Consumer Information and Insurance Oversight (CCIIO) outlining how Essential Health Benefits should be improved to protect patient health.

The essential benefits are the minimum coverage floor for health plans sold on the state and federal marketplaces, as well as Medicaid expansion plans. Each state determines its own essential benefits, which must include 10 categories of coverage (including mental health and substance use benefits). Though the law is designed to ensure that all Americans have access to meaningful and comprehensive health coverage, in practice, commonly used benefit limitations have prevented individuals with serious health conditions such as mental illness, HIV/AIDs, or epilepsy from accessing important services they need.

Our group’s letter points out that qualified health plans are making use of formulary restrictions, fail-first and prior authorization requirements to sharply limit the availability of certain classes of medications used frequently by people with costly chronic health conditions. Many plans do not have a process for quickly adding newly approved drugs to their formularies, further limiting the availability of lifesaving medications. High levels of cost sharing imposed on these drugs and a lack of transparency in formulary and provider network design have also posed a barrier for patients who need to access specialty care or medications. Our groups request CCIIO to address these concerns by issuing new guidance to insurance plans on how they must comply with the non-discrimination provisions of the Affordable Care Act, which prohibit plans from using benefit design as a tool to dissuade individuals with high health care needs from enrolling in the plan.