Determination of Essential Health Benefits

Improving the Health Insurance Marketplace Essential health benefits

Longstanding AMA policy aims to maximize patient choice of health plans and their respective benefits package, including by strongly supporting the role of health savings accounts. As such, the AMA realizes that patients define essential benefits differently, based on their health needs and budgetary restrictions. At the same time, the AMA recognizes that children’s health care needs are different from those of adults, and believes that ensuring a comprehensive and robust essential health benefits (EHB) package is critically important for children, especially those who have special health care needs.

The AMA supports: maximizing the choice of health plans and benefits packages for adults; using the Medicaid program’s Early and Periodic Screening, Diagnostic, and Treatment benefits as the model for any EHB package for children; and minimizing state benefit mandates that are included in the EHB package to ensure the affordability of health insurance coverage.

The American Medical Association (AMA) believes required to offer at least the EHB package, that the definition of essential health benefits (EHB) including those offered in health insurance should strive to maximize patient choice of health exchanges and in the individual and small group plans and their respective benefits packages. The AMA markets outside of exchanges (see “Health recognizes that the requirements of the EHB package insurance exchanges” in this series). will strongly impact health care premiums and costs. Therefore, the criteria for the EHB package for adults • The ACA specified that the EHB package must cover need to be flexible to enable patient choice of health the following general categories of services: plan and the respective benefits covered while still offering meaningful coverage. Such flexibility would - Ambulatory patient services also allow high-deductible health plans coupled with - Emergency services health savings accounts (HSAs), as well as consumer- - Hospitalization driven health plans, to continue to operate in the - Maternity and newborn care health insurance marketplace. The health care needs - Mental health and substance use disorder services, of children are unique and differ from those of adults, including behavioral health treatment which is why AMA policy advocates that services to - Prescription drugs children, adolescents and young adults should meet - Rehabilitative and habilitative services and devices Early and Periodic Screening, Diagnostic, and Treatment - Laboratory services (EPSDT) standards. - Preventive and wellness services and chronic disease management Patient Protection and Affordable Care Act - Pediatric services, including oral and vision care provisions • The Secretary of the U.S. Department of Health • The Patient Protection and Affordable Care Act and Human Services (HHS) has the responsibility (ACA), Public Law 111-148, included provisions to determine the scope of the EHB package, which to create an EHB package. All qualified health the ACA specified should be equal to the scope of benefits plans, with the exception of grandfathered benefits under a typical employer-sponsored plan. individual and employer-sponsored plans, are

Page 1 (Continued on page 2) HHS final rule on essential health benefits out-of-pocket costs. Similarly, the AMA firmly believes that the determination of an essential health benefits Regulations addressing EHB stated that EHB shall be package should not undercut the vital role in the health defined by state-specific benchmark plans through at insurance marketplace of high-deductible health least the 2017 benefit year. HHS also stated that “the insurance plans issued to individuals and families in EHB-benchmark plan would serve as a reference plan, conjunction with HSAs. reflecting both the scope of services and limits offered by a typical employer plan in that state.” Use the EPSDT benefit as the model for children

HHS outlined four benchmark plan options for states: The health care needs of children are unique and differ from those of adults. Ensuring a comprehensive and • The largest plan by enrollment in any of the robust EHB package is critically important for children, three largest small group insurance products in especially those who have special health care needs. the state’s small group market Failure to ensure an adequate scope and design of • Any of the largest three state employee health benefits for children can result in life-long health benefit plans by enrollment consequences with extensive and, in many cases, • Any of the largest three national Federal avoidable costs. Employees Health Benefits Program (FEHBP) plan options by enrollment Using the EPSDT benefit as a model for any EHB • The largest insured commercial non-Medicaid package for children ensures that all preventive, health maintenance organization operating in diagnostic and treatment services that are medically the state necessary for children are covered. When comparing EPSDT and private health plan coverage, there are several differences in coverage, which result from Strategies to foster healthy markets children and adults having different health care needs. Generally, certain children, especially those with special Maximize choice of health plans and benefit health care needs, face gaps in coverage under private packages for adults health plans that would not otherwise exist if provided the EPSDT benefit. Under EPSDT, children enrolled in The AMA believes that the definition of EHB should the Medicaid program have access to comprehensive maximize patient choice of health plans and their health care, including preventive health care services respective benefits packages, including strongly that include but are not limited to immunizations, supporting the role of HSAs. Existing federal guidelines physical exams, dental and vision care, and mental regarding types of health insurance coverage (e.g., Title health and hearing screenings. And, most importantly, 26 of the U.S. Tax Code and Federal Employees Health medically necessary diagnostic services and treatment Benefits Program regulations) should be used as a must be provided to address any conditions or needs reference for EHB for adults. These existing regulations identified during the screening process. have reflected the reality that patients define essential benefits differently, based on their health care needs Minimize state benefit mandates and budgetary restrictions. At the same time, they make clear that health insurance should provide coverage Benefit mandates should be minimized to allow for hospital care, surgical and medical care, and markets to determine benefit packages and permit catastrophic coverage of medical expenses, as defined a wide choice of coverage options. Increasing the by Title 26, Section 9832 of the U.S. Code. number of state mandates included in the EHB package will result in an increase in the cost and reduce the Health insurance issuers offering options that provide affordability of health insurance coverage, affecting the coverage of at least the EHB package should still have ability of individuals and small businesses to purchase the ability to respond to patient demand for ample health insurance coverage due to higher premiums. health plan choices, in terms of benefits covered and

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