NHeLP Breaks Down Five Key Health Reform Standards

Executive Summary

Understanding how access to family planning services will be impacted in Exchanges and Medicaid in the coming years requires understanding five key terms in the Affordable Care Act (ACA) which interact with each other in complex ways.

1. Qualified Health Plans (QHPs)
Qualified Health Plan is simply the name given to the health insurance plans that will be allowed to be sold on the health care Exchanges created in health care reform.1 In order to qualify as a QHP, plans must cover at least all of the benefits included in the Essential Health Benefits package2 (discussed below), and must agree to comply with all of the insurance reforms enacted in the ACA such as the prohibitions on discrimination3 or on gender rating.4
One specific concern as CMS develops rules on QHPs is whether a plan that refuses to cover required reproductive health services based on a moral or religious objection can be certified as a QHP, and if so, what conditions will be imposed to ensure that enrollees get the covered services to which they are entitled in a timely and accessible manner. A ?refusal clause? is a statute, regulation, or policy that allows providers or institutions (or in this case a coverage policy) to refuse to provide or cover necessary medical care, such as family planning services, that would usually be required, based on moral or personal objections. The ACA allows refusals for QHPs only with respect to abortion, in that it prohibits ?discrimination? against any provider or facility because of its ?unwillingness to provide, pay for, provide coverage of, or refer for abortions.?5 The ACA does not explicitly authorize refusals to provide coverage for other services such as family planning services, emergency services, prescriptions, services to individuals based on their sexuality, and other essential women?s health services. Nonetheless, we expect religiously affiliated health plans to attempt to attain QHP status and retain their broad refusal policies.

2. Essential Health Benefits (EHB)

Essential Health Benefits (EHB) is a standard created in the ACA. EHBs are the minimum benefits package that Qualified Health Plans participating in an Exchange must cover.6 It will also the minimum standard for Medicaid Benchmark Plans7 (discussed below), and is also required in the group and individual markets through ACA reforms to the insurance market.8
The EHB package is only generally defined in the ACA,9 and this general definition includes coverage of ?maternity and newborn care? and ?preventive and wellness services? but does not explicitly mention family planning services and supplies. HHS is charged with providing a more specific definition of the benefits package, based on the general categories set out in the ACA. The final HHS standard on EHB will have a tremendous impact on the access of millions of women to comprehensive women?s health services.
In order to help develop the EHB standard, HHS contracted with the Institute of Medicine (IOM) to develop recommendations on criteria for developing the EHB benefits package.10 NHeLP provided written recommendations, and was one of a small set of organizations invited to provide live testimony in the IOM process.11
Currently the IOM is preparing its final recommendations, which it is expected to provide to HHS by September 1, 2011. HHS will use the IOM recommendations to develop a final policy, which is expected to be released as a regulation12 soon after it receives the IOM
One related question is whether family planning services and supplies will be considered a ?preventive service? (discussed below). There is a separate IOM process to make recommendations to HHS as to which women?s health services should be required as ?preventive health services.?
Note further, the EHB standard also forms the minimum coverage standard for the Basic Health Plan option13 and a Multi-State Qualified Health Plan.14


3. Benchmark Plans
Benchmark benefits were created in Medicaid through the 2005 Deficit Reduction Act (DRA) as an optional alternative to the standard state Medicaid benefits package.15 Instead of being based on the traditional Medicaid covered services in the state, they can be based on any one of several ?benchmark? standards established by the DRA. For example, one Benchmark option is the typical plan available to state employees in the state.16 Through 2010, few states (about 8) have used this Benchmark authority to create Benchmark benefits packages.17
Health care reform vastly expands the role of Benchmarks by making Benchmark benefits the default benefits package for the Medicaid Expansion population (newly eligible individuals with incomes of up to 133% FPL).18 There are specific exceptions in the Medicaid statute for populations that are not allowed to be put in Benchmark packages (such as mandatorily covered pregnant women and women in breast and cervical cancer category programs).19
As mentioned, Benchmark benefits packages can generally be pegged to any one of the several ?benchmark? standards listed in the Medicaid Act.20 However, the ACA requires that all Benchmark packages must at least cover the EHB standard (discussed above).21 Thus, the EHB standard forms the minimum for individuals in Qualified Health Plans in the Exchange and the many Medicaid Expansion enrollees who will get a Benchmark benefit.
Significantly, the ACA22 expands the Medicaid coverage requirements of the Benchmark benefit to include family planning services and supplies.23 Therefore, regardless of whether the EHB standard includes it, family planning must be included in any Benchmark plan. Further guidance on the Benchmark benefit appears in a July 2, 2010, Dear State Medicaid Director letter discussing Family Planning Services and Benchmarks.24
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