Last Friday afternoon, the Centers for Medicare and Medicaid Services (CMS) under the Department of Health and Human Services (HHS) published the highly anticipated 2016 Notice of Benefit and Payment Parameters (BPP) rule. The BPP addresses a number of consumer priorities for qualified health plans in 2016, ranging from rate review and language access to the essential health benefits (EHB) package and inclusion of essential community providers (ECPs). As Community Catalyst begins to sift through this important rule, we wanted to share information regarding the approach to the EHB package, which is the baseline set of benefits included in health plans both inside and outside Marketplaces.

As a refresher on where we left off with the EHB, read more here. This post may also be useful – it considers how advocates can weigh in on some of the following issues to address discrimination in health plans and promote health equity.

As consumer advocates, we were hopeful that the BPP would introduce an improved approach to the development of the EHB package. For better or for worse, HHS proposes to stay the course with EHB. Below is an overview of key changes to the EHB – and opportunities for advocates to weigh in to influence the final rule –  within the next 30 days when comments are due.

The benchmark approach continues and gives states future flexibility to choose a new benchmark plan from 2014 portfolio of health plans. There are no signals that HHS intends to alter the benchmark approach but rather HHS offers states an opportunity to re-evaluate their choice in the future. Starting in 2017, states will choose a new benchmark from 2014 plans, supplementing as needed to ensure all EHB categories are met. It will be important for advocates to reflect on where state EHBs fell short and where supplementing is an important tool in creating robust state EHB benchmarks.

HHS wants a uniform habilitative care definition. The National Association of Insurance Commissioners defines habilitative care as “health care services that help a person keep, learn or improve skills and functioning for daily living.” In terms of habilitative care as a benefit, however, the definition is less clear. In the first round of EHB development, states or insurers defined habilitative care, leading to highly variable definitions, some more restrictive than others. HHS proposes and seeks comment on a proposed definition (taken from the Glossary of Health Coverage and Medical Terms). Additionally, HHS clarifies that rehabilitative services are a distinct category of habilitative care – this is important so that limits on these services are separate, increasing consumer access to needed care. This is an opportunity for consumer advocates to provide comments to show their support of a new definition and/or offer feedback for strengthening the definition.

Children remain covered through 19th year. The rules make an important clarification that children continue to have access to pediatric services through their 19th year, ensuring continuity of care.

HHS highlights discrimination in benefit design. HHS warns insurers that it is prohibited to design plans in a discriminatory way and that HHS and/or state regulators may demand that insurers explain their benefit designs. HHS provides examples of discriminatory designs, such as limiting access to benefits based on age or placing drugs for a specific condition in the highest cost tier. Consumer advocates have an opportunity to weigh on developing a stronger, more transparent approach to holding insurers accountable.

Drug approach redesigned. HHS proposes extensive changes to drugs – including the requirement that insurers develop pharmacy and therapeutics (P&T) committees. These committees would be comprised of physicians, pharmacists, specialists and others that would assist in guiding formulary development. Additionally, HHS proposes an exceptions process that would enable physicians and/or consumers to gain access to clinically appropriate off-formulary drugs within 72 hours. There are also new transparency measures that require formularies to be published online. There are a number of additional changes that you can learn about here. This is a significant change that will require ongoing monitoring by consumer advocates as a new process is implemented.

Out-of-network provider cost sharing can be counted toward annual limit. Many will recall the frustration that out-of-network cost sharing could not be counted toward a consumer’s out-of-pocket maximum. HHS proposes in this rule to give flexibility to insurers to determine whether or not out of network costs can count toward out-of-pocket costs.

Data, data, data. HHS proposes data collection on EHBs from 2014 to improve the benchmark selection. They note that the data collection requirement was inadvertently omitted in earlier regulations. HHS will begin collecting data on current EHBs that will help, we hope, with states’ benchmark selection in 2017. Again, this is a great opportunity for advocates to propose which data elements will be most useful in helping everyone understand how the EHB is and is not meeting consumers’ health needs.

The time to comment is short, only 30 days, making December a busy month with many different opportunities to weigh in with HHS about EHB and other important consumer priorities. Stay tuned as we continue the conversation about additional elements of the rule and action steps for advocates.