Government must protect consumers from limited-benefit plans, AHA says

The American Hospital Association (AHA) wants the federal government to close a loophole in coverage requirements for employer-sponsored plans that it claims can harm consumers and hamper healthcare reform.

In a Feb. 16 letter to Centers for Medicare & Medicaid Services (CMS) Acting Administrator Andrew Slavitt and IRS and Treasury Deputy Commissioner for Services & Enforcement John Dalrymple, the AHA says it's concerned that some emerging employer-sponsored health plans do not cover outpatient surgeries. The letter says health plans that do not cover such surgeries put enrollees' physical and financial health at risk; violate the Affordable Care Act's promise of comprehensive, affordable coverage; and hamper efforts to transform the delivery system.

Large employers are not required to offer a list of "essential health benefits" in the same way individual-market plans do, so some employer plans are starting to exclude outpatient surgeries to cut costs, FierceHealthPayer previously reported. These plans cover inpatient care and diagnostic imaging, but not cover outpatient surgery, which saves companies a lot of money but can leave employees with high medical bills.

The AHA letter urges CMS and the Treasury to mandate employer-sponsored coverage of hospital outpatient surgeries, close any remaining loopholes and ensure that coverage be substantial enough within each category of benefits. To achieve this, AHA recommends that CMS "consider establishing a benchmark for what services within each category must be covered to be considered substantial," as well as set minimum values as if the benefit category were stand-alone.

Finally, the letter notes that some consumers have chosen to decline their employer's coverage and instead pay full market price for a comprehensive plan. Others cannot afford full market price for these plans, so they are forced to pay out-of-pocket for uncovered services, receive no care or find a similar service through inpatient settings.

To learn more:
- read the AHA letter (pdf)