Essential Health Benefit: BIO's Comments on the HHS Pre-rule Bulletin

The Biotechnology Industry Organization (BIO) is pleased to submit the following comments on the Department of Health and Human Services' (HHS) pre-rule bulletin on the essential health benefit (EHB) provisions of the Patient Protection and Affordable Care Act (PPACA).

            BIO represents more than 1,100 biotechnology companies, academic institutions, state biotechnology centers and related organizations across the United States and in more than 30 other nations. BIO's members develop medical products and technologies to treat patients afflicted with serious diseases, to delay the onset of these diseases, or to prevent them in the first case.  In that way, our member's novel therapeutics, vaccines, and diagnostics not only have improved health outcomes, including productivity and quality of life, but also have reduced health care expenditures due to fewer physician office visits, hospitalizations and surgical interventions.

            PPACA requires non-grandfathered plans in the individual and small group markets both inside and outside of the state health insurance exchanges,[1] Medicaid benchmark and benchmark-equivalent,[2] and basic health programs[3] to cover EHB beginning in 2014.  The essential health benefits package comprises ten categories of items and services, including prescription drug coverage,[4] and may not “discriminate against individuals because of their age, disability, or expected length of life.”[5]  The statute requires HHS to define the EHB through a notice and public comment process.[6]

            BIO appreciates HHS' decision to provide the states with the flexibility to select a benchmark plan best suited to provide the necessary coverage for their individual populations. We believe this flexibility will allow for greater competition among health plans in every region, thereby increasing patient choice.  At the same time, we urge HHS to prioritize patient access in future rulemaking, particularly as the Department considers how best to evaluate plan formularies to ensure that Exchange enrollees have broad access to critical therapies.  The EHB package must be comprehensive and affordable, and must promote a standard that prevents individuals from underinsurance, a growing national trend that cuts across age and income level. Additionally, we urge HHS to issue specific guidance on how the Secretary will ensure that the EHB requirements protect all patients from discriminatory benefit designs, especially those with diverse healthcare needs.   

[1]See Patient Protection and Affordable Care Act (“PPACA”) § 1301(a), Pub. L. No. 111-148,124 Stat. 119, 162-163, as amended by PPACA § 10104(a), 124 Stat. at 896 (codified at 42 U.S.C.S. § 18021(a) (LexisNexis 2011)).

[2]Id. at § 2001(c), 124 Stat. at 276-277 (codified at 42 U.S.C.S. § 1396u-7(b)(5) (LexisNexis 2011)).

[3]Id. at § 1331, 124 Stat. at 199-203, as amended by PPACA § 10104(o), 124 Stat. at 902 (codified at 42 U.S.C.S. § 18051 (LexisNexis 2011)).

[4]Id. at § 1302(b)(1), 124 Stat. at 163-164 (codified at 42 U.S.C.S. § 18022(b)(1) (LexisNexis 2011)).  The ten categories are: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventative and wellness services and chronic disease management; and pediatric services, including oral and vision care.

[5] Id. at § 1302(b)(4)(B), 124 Stat. at 164 (codified at 42 U.S.C.S. § 18022(b)(4)(B) (LexisNexis 2011)).

[6] Id. at § 1302(b)(3), 124 Stat. at 164 (codified at 42 U.S.C.S. § 18022(b)(3) (LexisNexis 2011)).