Payers, providers clash over scope of CMS review of ACA's essential health benefits

Insurers pressed the Biden administration not to add new responsibilities for payers under the Affordable Care Act’s (ACA's) essential health benefits. 

Providers and patient groups, on the other hand, argued more enforcement needs to be done to remove barriers to care caused by plans such as prior authorization and inappropriate denials of coverage. 

Several groups and companies gave comments earlier this week on a request for information from the Centers for Medicare & Medicaid Services (CMS) on the ACA’s essential health benefits. The law requires payers to cover 10 essential services, ranging from inpatient hospital care to prescription drug coverage.

Provider groups such as the American Hospital Association (AHA) warned that CMS should look to combat unnecessary barriers to care that have emerged from certain health plans. These include “improper use of utilization management programs, inappropriate denials of medically necessary covered services … and mid-contract year changes to patients’ coverage,” their comments said. 

“Overall, there is mounting evidence that these problematic health plan practices are growing,” the AHA wrote. “Government agencies, as well as courts and arbitrators, have continued to uncover concerning findings with respect to certain commercial insurer conduct.”

The AHA called on CMS to ensure adequate oversight of plans and address inappropriate use of prior authorization as well as payment denials. CMS has published regulations recently aimed at increasing the use of electronic prior authorization and other reforms to hasten approvals of such items or services. 

The group also pushed for improvements to the coverage of behavioral health services, a growing concern in the healthcare industry as demand for such services has skyrocketed. 

The AHA called on CMS to improve the specificity of “what mental and behavioral health services are included” in the benefits and require plans to explicitly list services of most interest to patients including outpatient services and peer support. 

“Plans should include this list of covered services as they do prescription drugs in their plan benefit summaries,” the AHA said. 

A collection of 50 patient groups wrote in comments to CMS that there need to be some improvements to the prescription drug coverage benefits available to patients. 

Chief among the requests is that CMS increase the number of drugs an insurer has to cover in a certain class. Currently, the minimum requirement is for a plan to cover either one drug per category or class or at least the same number of drugs in every U.S. Pharmacopeia category and class as covered by the essential health benefits benchmark plan. 

“Often times this is not a sufficient number of drugs to meet the needs of patients with complex and severe health conditions,” according to the letter which includes groups such as the HIV+Hepatitis Policy Institute and the Alliance for Patient Access. 

No more benefit mandates

Several payers commented, on the other hand, that CMS needs to weigh whether to add any more benefit mandates. Insurer group AHIP warned CMS against increased federal standardization for health benefits, noting there isn’t any evidence that regulators are having challenges interpreting coverage. 

“Additional federal standardization could have unintended consequences, conflict with state laws, disrupt local markets and restrict issuers’ flexibility to develop new and additional plan designs,” AHIP wrote in comments. 

The group was also concerned about states’ ability to require plans to cover benefits beyond the ACA, as long as the state defrays the cost of these additional benefits.

“We have longstanding concerns that states have enacted benefit mandates, some with lack of supporting medical evidence, without offsetting the cost of these state-required benefits,” AHIP wrote. 

Centene added in comments that any expansion of benefits “demands careful consideration of the likelihood that such changes will increase healthcare costs overall compared to the potential improvements in population-level health outcomes.”