Last Friday afternoon, the Centers for Medicare and Medicaid Services (CMS) under the Department of Health and Human Services (HHS) published the highly anticipated 2016 Notice of Benefit and Payment Parameters (BPP) rule. The BPP addresses a number of consumer priorities for qualified health plans in 2016, ranging from rate review and language access to the essential health benefits (EHB) package and inclusion of essential community providers (ECPs). As Community Catalyst begins to sift through this important rule, we wanted to share information regarding the approach to the EHB package, which is the baseline set of benefits included in health plans both inside and outside Marketplaces.
HHS wants a uniform habilitative care definition. The National Association of Insurance Commissioners defines habilitative care as “health care services that help a person keep, learn or improve skills and functioning for daily living.” In terms of habilitative care as a benefit, however, the definition is less clear. In the first round of EHB development, states or insurers defined habilitative care, leading to highly variable definitions, some more restrictive than others. HHS proposes and seeks comment on a proposed definition (taken from the Glossary of Health Coverage and Medical Terms). Additionally, HHS clarifies that rehabilitative services are a distinct category of habilitative care – this is important so that limits on these services are separate, increasing consumer access to needed care. This is an opportunity for consumer advocates to provide comments to show their support of a new definition and/or offer feedback for strengthening the definition.
Children remain covered through 19th year. The rules make an important clarification that children continue to have access to pediatric services through their 19th year, ensuring continuity of care.
HHS highlights discrimination in benefit design. HHS warns insurers that it is prohibited to design plans in a discriminatory way and that HHS and/or state regulators may demand that insurers explain their benefit designs. HHS provides examples of discriminatory designs, such as limiting access to benefits based on age or placing drugs for a specific condition in the highest cost tier. Consumer advocates have an opportunity to weigh on developing a stronger, more transparent approach to holding insurers accountable.