It seems like a distant memory when states had to choose their Essential Health Benefit (EHB) benchmark plans, the benefit baseline that all new individual and small group plans, including Qualified Health Plans (QHPs), have to cover. However, according to recently released regulations, this process will repeat itself, as states have the option to pick new benchmark plans for the 2017 plan year based on a 2014 health plan.
For many consumers, the EHB benchmark plans have fallen short. We applaud the federal response to address some of these shortfalls through proposed regulation, including a re-examination of prescription drug inclusion in the EHB. However, gaps remain. With one year of EHB coverage behind us, we know that consumers have struggled to access critical care addressing substance use disorders, pediatric services related to hearing, vision, and behavioral health, and habilitative services. The inadequacy in EHBs forces many families to forgo needed services or pay out of pocket for a loved one’s medical care. A robust benchmark plan selection will break down these barriers and allow consumers to access the services they need to keep themselves and their families healthy.
During the previous EHB benchmark selection process, who or what entity selected the benchmark plan varied from state to state, ranging from governors to legislatures to departments of insurance (check out this page to get more of a sense of the process in your state). On the other hand, 26 states either did not engage in the selection process or were unable to select a plan, and defaulted instead to the smallest group plan. Although some states might use a similar mechanism as last time to make the decision for 2017, shifting dynamics in many states will mean that there is not yet a definitive way the decision will or will not be made.
Advocating for the selection of a robust benchmark plan remains complicated. Consumer advocates last time around had varying roles in the process, ranging from sitting on workgroup tables and directly informing EHB benchmark selection, to providing input during public comment periods, and sometimes having no role at all. Many may remember the large “listening sessions” from the first round of EHB selection, which often felt overwhelming, lacked focus, and turned into a laundry list session of needed health services. Going forward, advocates will need to look back at what did or did not work last time and what strategies will work in the next round.
The timeline for a new EHB decision remains unclear. For the 2014 plan year, states selected their benchmark by September 2012 and the QHP certification process began in April 2013. The timeline for QHP certification remains similar in recent Center Medicare and Medicaid Services (CMS) regulations.
If we assume a similar federal approach to EHB selection and supplementing of benchmark plans, most states will need to make the decision for 2017 in the latter half of 2015 in anticipation of QHP certification beginning in the first half of 2016. While 2017 may seem far off, the opportunity to influence the decision and ensure meaningful consumer input is upon us.
The most pressing advocacy opportunity arises in states where the legislature makes the final benchmark call and where legislative sessions are short. Utah, Washington, New Hampshire, and California are four states where the legislature played a role previously, and their sessions end in March, April, June, and September respectively. To take advantage of the opportunity for states to revisit the benchmark plan selection, legislators will need to know that doing so is important to consumers in their state.
Advocates in all states must 1) press the responsible entity to revisit the benchmark plan in the first place, rather than simply deferring to the default plan, and 2) provide input about the selection of a plan that comprehensively meets the needs of consumers. This is not an issue to wait to react to – it is an issue that is our responsibility to bring to the forefront. One of the first steps in accomplishing this is to build the narrative around EHBs by identifying areas where current benchmark plans fall short and highlighting how it affects real families. EHBs will have a significant impact on the quality of care your friends, family and neighbors receive and it’s time to start the conversation about the EHB benchmark plan in your state.