Insurers, provider groups and patient groups are gearing up for a new round of fighting over the products and services a major medical insurance policy ought to cover.
The Centers for Medicare & Medicaid Services (CMS) says states will get to choose a new essential health benefits (EHB) benchmark plan for 2017.
Groups could use the EHB benchmark plan selection debate as a chance to talk about how plans should cover dental care for children, weight-loss surgery, therapy for children with developmental disorders, and other controversial classes of benefits.
CMS is putting the 2017 EHB plan selection system through a paperwork review process.
The first EHB benchmark plan selection process, which took place mainly in 2012, gave patient support groups a chance to lobby for richer benefits for the patients, and opponents of PPACA a chance to refuse to cooperate with CMS implementation of PPACA.
This time around, CMS expects to make a minor change in the selection process: Instead of having to fill out a separate form describing the EHB benchmark plan candidate, a state may be able to e-mail the plan’s form filing directly to CMS, without filling out a separate form.
The drafters of the Patient Protection and Affordable Care Act (PPACA) made the EHB the heart of the commercial health insurance market, and of the PPACA public health insurance exchange system. An EHB package is supposed to include coverage for 10 classes of benefits, such as maternity care, wellness care and hospitalization benefits.
A state and its health insurers determine whether a given health plans fits in the bronze, silver, gold or platinum “metal level” by calculating the percentage of the actuarial value of the EHB package that the plan covers.
CMS ruled in 2011 that each state should choose an EHB benchmark plan, or let CMS choose the benchmark plan. The benchmark plan can be one of the three largest small-group insurance plans in a state; any of the three largest employee health benefit plan options offered to a state’s state employees; any of the three largest national Federal Employees Health Benefits Program options; or a state’s largest insured commercial health maintenance organization (HMO) plan.