As we enter the fall of 2014, the window of opportunity to influence what benefits are required in Marketplace plans is opening. While the essential health benefits (EHB) package is already set for 2015, advocates have the opportunity to influence the EHB in the future. Although 2016 may seem far away, it is not when you consider the 2016 health insurance plan development timeline. The back-and-forth communications between insurers and departments of insurance will most likely start in the spring of 2015. The plan development timeline therefore pushes the advocacy timeline even earlier, shifting our attention to, well, now. So what should consumer health advocates be thinking about as they ponder a future EHB standard? Demand that decision makers get consumer input right.
EHB Take 1: Where did we end up?
In an interesting twist, the Department of Health and Human Services (HHS) delegated the task of EHB development to the states in response to the Institute of Medicine’s study of a potential EHB standard. In this “hot potato” hand off, states suddenly became the central decision maker as to what benefits would be included in their state EHB – within some boundaries, of course, set by HHS. States selected (or defaulted) a benchmark or reference plan from a list of plan options (three largest small group plans, three largest state employee benefit plans, three largest federal employee benefit plans, and the largest commercial HMO). You can read a refresher here.
In the final tally, the majority of states opted to use the largest small group plan for the benchmark. Advocates were frustrated by this outcome and overwhelmed by the process, which gave them no transparent path to provide the consumer perspective. As we head into the next selection process, we remain concerned about some key substantive challenges. These include but are NOT limited to how plans set limits on numbers of visits within benefit categories; how anti-discrimination provisions are (or are not) enforced on the federal level; how habilitative care (a new important benefit category especially for children and people with substance use disorders) is defined at the state level; how pediatric services are represented across all benefit categories; and how women’s health services are included in plans. These challenges are outlined in greater detail here.
Common frustrations for advocates from the 2014 EHB process included little or no state engagement, a lack of transparency about plan details, and no clear way for consumers to weigh in. While there were efforts to hold forums and/or offer comments, this was not consistent across states and they were often not fruitful because forums evolved into loose feedback sessions without clear agendas or facilitation.
Over this past year, advocates have continued to monitor how the EHB is or is not working for consumers. This work, largely without access to needed data, relies on consumer feedback, appeals, complaints, and input from assisters and Navigators—all of which, when pieced together, tell us the story of EHB. However, without a clear and transparent process, it will be challenging to influence the EHB moving forward. It is time to re-engage with stakeholders and openly discuss how to have a robust and transparent review of the EHB and determine its future. Advocates in Florida are beginning to think about how to have more public conversations about their state’s EHB to avoid what happened in 2012, when Florida leaders failed to choose a benchmark plan and defaulted to the small group plan option. Their proactive approach advocating for transparency in reviewing EHB provides us an example of how other states can jumpstart engagement with stakeholders.
EHB Take 2: Florida advocates demand consumer input.
As we move into the next phase of planning, Florida advocates remind us that we need to return to our overarching principle around EHB: a transparent, consumer-driven process that results in a robust benefit package for all consumers. Consumer health advocates can play a vital role in elevating consumer experience and informing the future shape of EHB. Advocates must elevate consumer stories and identify effective vehicles to amplify them to decision makers at the state and federal levels.
This past month, KidsWell Florida, led by Florida CHAIN, urged Florida Insurance Commissioner Kevin McCarty to use his authority to convene a workgroup tasked with reviewing and making recommendations on the state’s EHB package in time for the 2016 plan year. Advocates reached out to their coalition membership, encouraging them (and their partners) to sign on to a letter requesting that Commissioner McCarty play a proactive role reviewing its EHB package. Included in this request was a specific ask for consumer representation in a workgroup convened by the commissioner to review Florida’s EHB package.
While EHB differs among our 50 states, so do key concerns about EHB state level details. Florida advocates are particularly concerned about habilitative services. Advocates see a potential EHB workgroup as one vehicle to voice concerns about how habilitative services is defined and its impact on some populations – specifically, concerns about children’s access to critical health services. Given the possibility that any changes to EHB will require policy changes, Florida advocates are wasting no time engaging supporters and key stakeholders. So far, more than 25 Florida advocates, organizations and providers have signed on to the letter. And in late August, advocates from Florida CHAIN delivered and presented the letter to the commissioner at the Florida Health Insurance Advisory Board meeting.
Florida advocates’ approach provides one example of how state advocates can prioritize consumer issues as we all prepare for EHB: Take 2.