Proposed essential benefits rule to expand drug coverage


In addition to two other rules issued Tuesday, the U.S. Department of Health & Human Services released its proposed rule on the essential health benefits that insurers must provide in the individual and small group markets.

Under the rule, insurers must cover items and services within 10 categories--ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services.

HHS will defer to states to choose a benchmark plan that includes elements of these benefits to become the standard plan insurers must provide. If a state doesn't select a benchmark plan, HHS will choose the largest plan for small groups in the state, NPR reported.

Noteworthy among the rule's provisions is its prescription drug coverage requirement, which says insurers must at least cover the greater of the number of drugs per category in a state's benchmark plan or one drug. Since most states' benchmark plans include more than one drug per category, insurers must now meet "a significantly higher standard," Caroline Pearson, a director at Avalere Health, told Kaiser Health News. "It really ensures robust coverage, but you will have state-to-state variation."

Although HHS previously suggested it would propose a single-drug option, pharmaceutical companies and patient advocacy groups lobbied against that idea. As a result, insurers will have to cover far more drugs than they hoped.

The new policy "will significantly broaden access to branded pharmaceuticals for patients who buy their insurance on the exchange," Avalere Health CEO Dan Mendelson told Bloomberg. It will "make exchange offerings more consistent with employer offerings," he said, adding that costs for plans sold on exchanges also may increase.

To learn more:
- here's the HHS proposed rule and factsheet
- see the Kaiser Health News article
- read the NPR article
- check out the Bloomberg article

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