State-based Health Insurance Exchanges

AAFP Says HHS' Essential Health Benefits Guidance Falls Flat

January 10, 2012 04:55 pm News Staff

The Academy wasted no time voicing its displeasure with a bulletin recently released by HHS outlining the agency's general approach to defining essential health benefits that must be covered by insurance plans offered in state-based health insurance exchanges in 2014.

CMS' Essential Health Benefits Bulletin( simply says states can choose one of several existing state plan types. But the AAFP wants more specificity than what CMS is offering currently.

In a Dec. 19 news release, AAFP President Glen Stream, M.D., M.B.I., of Spokane, Wash., said the Academy wants detailed language, including "establishment of a robust national standard," that would make it clear that the provision of primary care services is essential to keeping patients healthy and keeping health care costs down. "The AAFP hopes that HHS follows up this bulletin quickly with an actual proposed regulation and that HHS specifies that primary care services performed by family physicians are essential."

Stream said studies show that when patients have a patient-centered medical home -- a health care setting in which primary care physicians form the foundation of the health care team -- "illnesses are prevented, complications of chronic conditions are avoided, unnecessary hospitalizations are reduced, patients have better outcomes and costs are constrained."

The Academy was disappointed that the recent bulletin did no more than reiterate ideas already clearly outlined in the Patient Protection and Affordable Care Act, such as the creation of 10 specific benefit categories that all basic health programs must cover. Those categories are

  • ambulatory patient services,
  • emergency services;
  • hospitalization;
  • maternity and newborn care;
  • mental health and substance use disorder services, including behavioral health treatment;
  • prescription drugs;
  • rehabilitative and habilitative services and devices;
  • laboratory services;
  • preventive and wellness services and chronic disease management; and
  • pediatric services that include oral and vision care.

Although some of the health care services most often provided to patients by America's family physicians are included on the list, the language in the recent bulletin clearly did not satisfy Stream.

He said HHS had much work left to do to flesh out details about the state exchanges and that the Academy stood ready to work with HHS, states, and prospective exchange entities to "continue developing their benefit packages so that the state-based exchanges offer a reliable and comprehensive range of services in 2014."

HHS is inviting public comment on the information provided in the bulletin through Jan. 31.