Last month, the Obama Administration took an important step toward implementing the Affordable Care Act (ACA) with the release of a number of long-awaited insurance regulations. Among other things, these new guidelines direct which essential health benefits (EHB) individual and small group health insurance plans must cover beginning in 2014.
The announcement represented a marked improvement over earlier guidance on the topic released in December 2011. But with the public comment period for the new rules ending on December 26, it's worth noting some important modifications that are still necessary.
The current rules are weak when it comes to non-discrimination standards and requirements that plans be balanced across categories of benefits. The proposed rule simply leaves it to states to develop definitions and standards for both of these plan requirements that were established by the ACA.
As it stands, states will have the main responsibility for making sure qualified health plans meet all federal and state standards. This may not be enough to guarantee that people with chronic diseases and disabilities have access to the benefits they are entitled to under the ACA.
If, for instance, an insurer fails to offer coverage for rehabilitative and habilitative services -- to name just one EHB category -- it's the state's job to take action. It's possible that some states will fail to live up to their enforcement responsibilities. If that happens, there's little the federal government could do under the newly released guidelines to make sure that citizens are getting the coverage they deserve.
As a result, we must put in place a federal monitoring system. Such federal oversight should be rigorous and data driven, using regular audits by the federal government, together with targeted reviews to keep tabs on state performance.
In addition, the federal government needs to provide a uniform standard for what counts as medically necessary. Such a standard should be objective, easily understandable, and universally applicable. The creation of a single, unified medical necessity standard not only would help patients understand the coverage criteria for specific items and services, but it also would ease the burden on navigators and assisters who will work with patients to navigate their health plans in this new coverage environment.
The new regulations also introduce requirements that enable patients to request necessary medications that aren't covered by their existing plan. This is an incredibly valuable provision, but it doesn't go far enough.
The federal government must standardize the process for requesting coverage for medications not covered by a health plan. Such an "exceptions process" is already available to participants in the Medicare Part D drug benefit. In Part D, patients seeking to obtain an off-formulary drug can seek a written request from their health care provider. Plans must render a determination within 24 hours for expedited requests. There is also a process for asking for reconsideration if a request is denied.
Finally, there is room for improvement in how the current ACA regulations measure "actuarial value." This is a measure of the amount of health care costs a given insurance plan will cover, and it is intended to help patients make comparisons between different insurance policies. Regularly updating this calculator so that it reflects real world data will help provide patients and health care consumers with the knowledge they need to make informed coverage decisions.
These changes may appear small, but as ACA implementation moves forward, policy alterations like these are going to play an enormous role in making sure that all Americans gain access to the quality, affordable health care envisioned by the Affordable Care Act.