Health plans miss the mark on essential drug benefits

Health plan drug benefits in Massachusetts and California don't meet essential health benefits requirements, even though the plans received approval, according to research in the American Journal of Managed Care.

The study looked at the lists of drugs covered by the three largest small-group plans in California and Massachusetts, and compared their drug formularies to the states' benchmark plans. Although healthcare reform in Massachusetts served as a model for the national law and California boats the largest state-run exchange, neither state fully complies with state and federal rules.

The study found minor inconsistencies in drug coverage between benchmark and nonbenchmark plans. For example, looking at state mandates, all three plans in California cover all smoking cessation products and all osteoporosis products. But the plans failed to cover 3 percent of antidepressants and 3 percent of antipsychotics.

Easing concerns that health plans lean toward minimum coverage if minimum standards are established, the study showed the plans go above the one-per class requirement and cover multiple drugs per class.

However, the study did reveal major differences related to cost sharing and reimbursement, including variations in prior authorization, step edits and quantity limits--which suggest conflicting strategies for designing formularies.

"The key question for policy makers is how well an essential health benefits approach balances consumers' desire for an affordable and comprehensive benefit package, while offering flexibility with respect to formulary benefit design and hence leverage for competitive pricing," the authors wrote.

While the authors called for implementing a value-based insurance design, a February Health Affairs study concluded value-based insurance design programs may need to target specific populations and run for years before payers and patients can reap significant gains from them.

And for more proof of a lack of coverage conformity: Most of the healthcare services excluded in the pre-Affordable Care Act insurance market have remained excluded in the ACA era. About 80 percent of pre-healthcare reform coverage exclusions are still among the most frequently excluded by ACA plans, according to a recent study from HealthPocket, which found 10 services with exclusion rates of 59 percent or more.

For more:
- here's the research announcement
- check out the study abstract

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