CMS Health Benefits Proposal Raises Red Flags for AAFP

Academy Proposes Standard Primary Care Benefit for Better Outcomes, Lower Costs

November 29, 2017 12:17 pm News Staff

The AAFP recently responded to a proposed rule from CMS that was published in the Nov. 2 Federal Register( and that sets forth payment and benefit parameters for health insurance marketplaces in 2019 and beyond.

[explanation of benefits form and stethoscope]

Family physicians may recall that the marketplaces (formally called exchanges) became operational in January 2014 as part of the Patient Protection and Affordable Care Act (ACA), and are intended to provide health insurance options to certain consumers.

According to an AAFP overview on the topic, the Academy strongly supports the ACA marketplace plans because they increase access to health care by providing affordable health insurance to the public.

Therefore, it's no surprise that the AAFP expressed concerns about some critical elements of the proposed rule in a Nov. 21 letter(3 page PDF) to CMS Administrator Seema Verma, M.P.H., that was signed by AAFP Board Chair John Meigs, M.D., of Centreville, Ala.

For instance, the proposed rule would give states more flexibility in selecting essential health benefit benchmark plans on an annual basis and would offer states many more than the 10 benchmark plan options to which they are currently limited. The proposal says a state's benchmarks must be "equal to the scope of benefits provided under a typical employer plan" and defines "typical" by referencing the number of people (5,000) covered by a single plan.

Story Highlights
  • In a recent letter to CMS, the AAFP outlined concerns regarding a proposed rule on payment and benefit parameters for health insurance marketplace plans in 2019 and beyond.
  • The AAFP questioned the proposed flexibility states would have in selecting essential health benefit benchmark plans.
  • The Academy cautioned CMS about the increase in high-deductible plans and proposed the establishment of a standard primary care benefit to ensure patient access to primary health care.

"The AAFP is concerned that a single outlier plan with minimum benefits could now count as typical, even if it's much less generous than other plans in the market," the Academy responded, noting that the proposed change could potentially allow states to scale back their essential health benefits by looking to a large employer with an unusually narrow health plan as their model.

Furthermore, "insurers could reduce or eliminate certain essential health benefits to avoid vulnerable, expensive patients by excluding specific services," says the AAFP.

The letter concedes that scaling back essential services could reduce plan costs and attract younger and healthier consumers. However, "it could have devastating implications for families with the sickest patients" by taking away coverage for medically necessary services.

Escalating deductibles and the "financial disconnect" that high deductibles create between physicians and their patients also raised a red flag with the AAFP. In response, the Academy introduced a solution.

"In an effort to maximize the proven benefits of health care coverage and a continuous relationship with a primary care physician, the AAFP proposes the establishment of a standard primary care benefit for individuals and families with high-deductible health plans."

The AAFP called for primary care visits to be exempt from deductibles and copayments and said the creation of such a benefit would keep patients connected to health care and "serve as a guardrail against disease progression that leads to more costly care."

Furthermore, under the AAFP's proposal, companies issuing high-deductible health plans would be required to provide full coverage of primary care services for the plan year and to include prevention, wellness and care management services that use

  • evaluation and management codes 99201-99215 for new and existing patients,
  • prevention and wellness codes 99381-99397,
  • chronic care management codes, and
  • transitional care management codes.

The letter noted that ensuring patient access to primary care is "sound economic policy" and referenced 2016 research( conducted by Portland State University that focused on implementation of the Patient-Centered Primary Care Home program.

Researchers found that each dollar spent on primary care resulted in a savings of $13 for other health care services, including subspecialty, emergency and inpatient care.

In summary, the AAFP said essential health benefit coverage of primary care services would lead to higher utilization of primary care, better health outcomes and lower costs.

The ever-increasing surge in high-deductible health plans nationwide increases the need to "incentivize and prioritize primary care," said the AAFP.