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.

As a refresher on where we left off with the EHB, read more here. This post may also be useful – it considers how advocates can weigh in on some of the following issues to address discrimination in health plans and promote health equity.

As consumer advocates, we were hopeful that the BPP would introduce an improved approach to the development of the EHB package. For better or for worse, HHS proposes to stay the course with EHB. Below is an overview of key changes to the EHB – and opportunities for advocates to weigh in to influence the final rule –  within the next 30 days when comments are due.

The benchmark approach continues and gives states future flexibility to choose a new benchmark plan from 2014 portfolio of health plans. There are no signals that HHS intends to alter the benchmark approach but rather HHS offers states an opportunity to re-evaluate their choice in the future. Starting in 2017, states will choose a new benchmark from 2014 plans, supplementing as needed to ensure all EHB categories are met. It will be important for advocates to reflect on where state EHBs fell short and where supplementing is an important tool in creating robust state EHB benchmarks.

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.

Drug approach redesigned. HHS proposes extensive changes to drugs – including the requirement that insurers develop pharmacy and therapeutics (P&T) committees. These committees would be comprised of physicians, pharmacists, specialists and others that would assist in guiding formulary development. Additionally, HHS proposes an exceptions process that would enable physicians and/or consumers to gain access to clinically appropriate off-formulary drugs within 72 hours. There are also new transparency measures that require formularies to be published online. There are a number of additional changes that you can learn about here. This is a significant change that will require ongoing monitoring by consumer advocates as a new process is implemented.

Out-of-network provider cost sharing can be counted toward annual limit. Many will recall the frustration that out-of-network cost sharing could not be counted toward a consumer’s out-of-pocket maximum. HHS proposes in this rule to give flexibility to insurers to determine whether or not out of network costs can count toward out-of-pocket costs.

Data, data, data. HHS proposes data collection on EHBs from 2014 to improve the benchmark selection. They note that the data collection requirement was inadvertently omitted in earlier regulations. HHS will begin collecting data on current EHBs that will help, we hope, with states’ benchmark selection in 2017. Again, this is a great opportunity for advocates to propose which data elements will be most useful in helping everyone understand how the EHB is and is not meeting consumers’ health needs.

The time to comment is short, only 30 days, making December a busy month with many different opportunities to weigh in with HHS about EHB and other important consumer priorities. Stay tuned as we continue the conversation about additional elements of the rule and action steps for advocates.

This guest blog post is the third blog in a series on discrimination in health plans. In this blog we highlight important successes in protecting access to coverage.

Dedicated advocacy has led to important successes in protecting health insurance coverage and health care access for people living with HIV. Below are three recent successes, both advocates working at the state and federal levels.

Illinois – Successful Advocacy for Regulations to Protect Consumers from Industry Practices. 

AIDS Foundation of Chicago, AIDS Legal Council of Chicago and Jenner & Block recently drew attention to harmful and discriminatory health insurance industry practices of Illinois health insurers. In response to discriminatory practices they observed within qualified health plans in Illinois, they sent a complaint to the Illinois Department of Insurance including specific examples of coverage exclusions, burdensome prior authorization processes and other problematic practices. In response, the Department of Insurance issued a bulletin to insurers suggesting plans that fail to cover all HIV drugs as recommended by the Department of Health and Human Services (HHS) and plans who institute burdensome and redundant prior authorization requirements may be found to be discriminatory.

Florida – Successful Advocacy for Lowered Cost-Sharing and Prices for Cigna Enrollees Living with HIV. 

The AIDS Institute and the National Health Law Program filed a complaint with HHS’s Office of Civil Rights regarding the discrimination practices that Cigna and three other Florida insurers implemented regarding HIV medications. These insurers placed all HIV medications, including generics, on specialty drug tiers. As a result, enrollees had to pay 40 percent – 50 percent of the cost of these medications, making them prohibitively expensive. Last month and in response to this complaint, Cigna entered into a consent order with Florida insurance regulators to agree to move generic HIV drugs to a lower-cost tier, limit copays to $200 a month for other HIV medications and to no longer require prior authorization for refills. The discrimination complaint is still under review by federal regulators.

National – Successful Advocacy for a Federal Rule Requiring Insurers to Accept Payments from Ryan White. 

As we discussed in a previous blog, health plans in some states stopped accepting premium payments from the Ryan White/AIDS Drug Assistance Programs on behalf of enrollees. This was problematic because many individuals living with HIV rely on Ryan White to assist with the financial burden of HIV treatment and care, including cost-sharing payments for HIV medications. The Centers for Medicare and Medicaid Services (CMS), in response and under pressure from advocates, released a rule requiring health insurance companies participating in the Marketplaces to accept third party payments from Ryan White. However, reports from other states indicate that health insurance plans have a tendency to lose track of third party payments, resulting in some consumers receiving termination from coverage warnings for “failure to pay premiums.”

It is critical to continue advocacy efforts to end discriminatory practices that pose barriers to meaningful coverage for people living with HIV.

-- Carmel Shachar and Malinda Ellwood, Center for Health Law and Policy Innovation, Harvard Law School

This guest blog post is the second blog in a series on discrimination in health plans. In this blog we highlight how discrimination in health plans affects people living with HIV/AIDS and policy recommendations to address the issue.

While the ACA expanded access to private health insurance plans for low-income individuals through the creation of the health insurance Marketplace and the provision of subsidies, increasingly industry practices are preventing people with chronic conditions like HIV from fully benefiting from the law. The barriers to meaningful health insurance coverage can be summed up in three categories:

  1. Lack of Transparency: One of the goals of the Marketplaces was to permit consumers to compare health insurance plans and make an informed decision about which plan best covered their health care needs. However, failure to include cost information (such as the actual price of a medication when a consumer is expected to pay co-insurance), lack of standardization of plan formulary information, inadequate information on drug coverage and essential provider networks, inconsistencies between the Marketplace and plan websites, and changes to plan design subsequent to enrollment seriously undermine the ability of consumers to select the right plan for them.

    Recommendations for Advocates: Further legislation and regulations are needed to strengthen transparency at the state and federal level. For example, in Nevada, the Department of Insurance proposed a regulation to limit the ability of plans to reclassify drugs after the end of open enrollment.  Consumers should also be educated on what kinds of information to ask for when selecting a plan, such as drug pricing and mail order pharmacy requirements.
  2. Inadequate Coverage of HIV Medications: Despite early advocacy efforts, many health insurance plans do not cover all HIV medications, including single tablet regimes (STRs), in accordance with the standard of care as recommended by the Department of Health and Human Services (HHS). In many states, plans are covering fewer protease inhibitors, the class of antiviral drugs widely used to treat HIV and hepatitis C, than required in the mandatory essential health benefits package (EHB) that plans offered on the exchanges are required to provide. In a recent assessment of the qualified health plans offered on 15 different health insurance Marketplaces, 28 percent of plans did not cover all HIV medications and 19 percent of plans did not cover STRs. The plans that do cover these medications may impose burdensome utilization review and prior authorization requirements, increasing the difficulty of accessing these medications for consumers.

    Recommendations for Advocates: To ensure consumers have access to adequate coverage of specialty drugs, an amendment to the EHB rule is needed to require coverage of specialty drugs where no generic alternatives exists that are widely accepted in treatment guidelines or best practices. In addition, HHS must strengthen the non-discrimination provisions of the ACA to protect people living with HIV/AIDS against formulary designs that do not serve their needs. Insurers should be educated about the health and cost benefits of STRs and consumers should be educated about the importance of checking plan formularies to make sure their required medications are covered.
  3.  Unaffordable Cost-Sharing Structures: Many plans are placing all HIV medications on formulary tiers with very high levels of cost-sharing. According to Avalere’s recent analysis, 50 percent of HIV/AIDS drugs covered on plans offered through the exchanges and eligible for tax credits and subsidies are subject to an average of 36 percent co-insurance. The high levels of co-insurance required can make HIV medications prohibitively expensive for consumers, even with health insurance coverage. Adding to the cost burdens of individuals living with HIV/AIDS, health plans in North Dakota and Louisiana stopped accepting premium payments on behalf of their enrollees from Ryan White/AIDS Drug Assistance Programs (a special federal and state partnership program for individuals living with HIV/AIDS that can help individuals pay premiums and co-pays in some states).

    Recommendations for Advocates: To ensure consumers have access to affordable medications under the plans offered, further regulations at the state and federal level are needed to prohibit excessive co-insurance for specialty drugs where no generic alternatives exist that are widely accepted in treatment. Specifically, HHS should amend the EHB rule to prohibit excessive co-insurance for specialty drugs where no generic alternatives exists that are widely accepted in treatment guidelines or best practices. Regulators should clarify that all Marketplace plans must accept private co-payment assistance. Additionally, there is a need for state and federal laws that limit cost-sharing for specialty and brand-name (when there is no generic alternative) drugs and a requirement to provide information on co-insurance requirements so that consumers can understand the actual price of medications under the plans offered

Continued Advocacy is Critical: What Can Advocates Do?

Advocates can help mobilize provider groups and consumers to demand that insurers and regulations address individual consumer needs and end discriminatory practices that pose a barrier to meaningful coverage.

  • Focus on consumer education during this upcoming open enrollment period: Consumers must be educated about a range of issues, including understanding terms like “co-insurance” and “deductible’ as well as checking plan formularies to make sure their required medications are covered. This plan assessment tool allows enrollment assisters to evaluate plans for their clients living with HIV and to empower advocates to monitor the Marketplaces for potential discrimination.
  • Emphasis on consumer voices: When barriers to care—lack of transparency, inadequate coverage, or discriminatory cost sharing—are observed, advocates should consider filing complaints with state departments of insurance and demanding the enforcement of the non-discrimination protections in the ACA, which prohibit plans from employing discriminatory marketing practices and benefit designs or failing to meet EHB requirements. Advocates should also consider filing complaints with the Office of Civil Rights and to use the court system to put pressure on insurers to forgo discriminatory practices.

While there is much work to be done, advocates in several states have successfully protected and secured access to health care coverage that does not discriminate against people with HIV/AIDS. Stay tuned for the next blog in this series to learn more.

-- Carmel Shachar and Malinda Ellwood, Center for Health Law and Policy Innovation, Harvard Law School

Navigators and assisters have hit the streets for round two of open enrollment for health insurance plans available as a result of the Affordable Care Act. With more people gaining access to care, this is a crucial time to strengthen the way we provide and pay for health care. Integrating services for drug and alcohol problems with other care can play a big role in transforming the health system and meeting goals of better care, better health and lower costs. The Centers for Medicare and Medicaid Services (CMS) are promoting this change in Medicaid, following a few states that are leading the way. Improving care for substance use disorder under Medicaid, which now covers at least 8 million people with substance use disorders, has the potential for profound change nationwide.

Let’s take a look at some service delivery innovations already underway. Washington state is using a prevention and early intervention model called SBIRT – screening, brief intervention, and referral to treatment to help prevent and treat drug and alcohol problem. This initiative reduced hospitalizations among Medicaid enrollees and led to significant savings for the state. Massachusetts saved money and improved care for Medicaid enrollees through medication-assisted treatment (MAT), which combines counseling with prescription drugs that blunt addiction. The research for MAT is strong but states are often reluctant to support it because it conflicts with traditional abstinence-based treatments. Massachusetts has opened the door for other states to use this evidence-based practice.

CMS is launching an initiative to promote more of this type of innovation by highlighting state successes, providing technical assistance and building a cross-state learning community. CMS spotlighted these best practices in a recent memo:

  • Provide a comprehensive benefit package for substance use disorders ranging from prevention to treatment to recovery services.
  • Integrate care for physical and behavioral conditions, incorporating the whole health of the patient by using health homes, primary care medical homes, and other integrated care models.Coordinate care across transitions in both physical and behavioral health care.
  • Implement prevention efforts and strategies to alleviate prescription drug misuse.
  • Head off alcohol and drug misuse in youth, including strategies in primary care such as Screening, Brief Intervention, and Referral to Treatment (SBIRT).

Advocates should urge their states to sign up for the Medicaid Innovation Accelerator Program (IAP) to learn from other states and get technical assistance from CMS. The program will feature monthly calls and webinars as well as hands-on support in preparing the technical documents (waivers or state plan amendments) that may be needed to help transform Medicaid to better treat substance use disorders. The deadline for submitting an "Expression of Interest" is this Friday, November 21. CMS is requiring stakeholder input from states that are selected to participate.

This initiative in Medicaid, coupled with other transformation projects, such as Accountable Care Organizations and the demonstration projects for people eligible for both Medicaid and Medicare, will help make our health system work better for all of us, including individuals with substance use disorders.

Impressive enrollment and reenrollment efforts are expected over the next few months. Let’s leverage this momentum and ensure all consumers – especially those with behavioral health care needs – have access to a coordinated and effective health care system.

Melissa Ough, policy analyst
and Alice Dembner, project director

We’re Calling the Play: Ready, Set, Enroll!

 The Affordable Care Act’s second open enrollment period starts tomorrow! On Saturday, November 15, millions of Americans can begin enrolling in and renewing their quality, affordable health coverage through the Marketplaces. Consumer health advocates and enrollment assisters have been planning for months, further developing the strategies they employed last year to reach the remaining uninsured and assist them with enrolling in coverage. To view the immense impact of their work last year, please watch our video: Getting to Covered.

 They are up to the task and will use innovative tactics, tools and tested messages to meet the goal for this open enrollment period.  Like a head coach before kickoff, we know advocates and enrollment assisters are fine tuning their game plans for this open enrollment season. Perhaps the biggest difference for this season is that advocates and enrollment assisters have two important audiences during this enrollment season: 1) the currently enrolled who need to renew and 2) the remaining uninsured. To reach these groups, we’ll have to use two playbooks.

Playbook 1: Helping Insured Consumers with Renewals

While recent research shows that the majority of consumers who enrolled last open enrollment season are satisfied with their plan, this same research also shows that most of the currently-insured are unaware of the renewals process. Though many consumers will be auto-enrolled in their 2014 plan, the features and benefits of their plan may change beginning in 2015, as well as the amount of financial assistance they may receive. To help ensure consumers enroll in the plan that best meets their needs, advocates and enrollment assisters should encourage currently-insured consumers to review the features of their current plan. In addition, we should work with people who have Marketplace plans to update their information so they continue to receive financial assistance. Lastly, consumers who need to renew should be encouraged to shop around to see if a different plan better meets their needs. Since the currently-enrolled value their coverage and are motivated to keep it, helping them renew hinges on letting them know what they need to do and when.

Playbook 2: Reaching the Remaining Uninsured

While the uninsured rate has dropped from 18.1 to 13.4 percent, which is the lowest uninsured rate since 2008, there are still millions of uninsured Americans in need of affordable coverage. Recent focus group research concluded that the remaining uninsured are less motivated to enroll than the those who were uninsured last year. In addition, they report that cost remains their main barrier to enrollment. However, many of the remaining uninsured are still unaware of the availability of financial assistance to help pay for the cost of premiums and cost-sharing obligations. Messages emphasizing that low-cost plans and financial help are available, as well as in-person application assistance, will be most effective at galvanizing the currently uninsured to explore their Marketplace plan options.

Knowing messages about financial help and in-person assistance are the most likely motivate consumers, what are the best ways to spread this message? Last year we learned that meeting consumers where they are, such as local, highly-frequented venues within the community, was a highly-efficient approach to reaching large amounts of community members in a small period of time. Additionally, using trusted messengers to spread enrollment messages, such as faith leaders, local or ethnic media sources, and family members, was a successful strategy to ensure those messages resonated with consumers. Lastly, lifting up the voices of those who’ve successfully enrolled through story banking can be a compelling way to motivate the remaining uninsured to explore their options.

Having groups of consumers with distinctly different enrollment needs is a change from last year’s open enrollment period, but the tools to achieve both goals are already in the hands of those who contributed to open enrollment’s success last year. Spreading the word about things that matter most to consumers – the renewal process, financial help, and in-person assistance – and using these messages by building on last year’s successful  tactics and strategies, is the playbook to follow to ensure millions of Americans gain or keep quality, affordable health coverage.