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Healthcare Reform Advocacy Opportunity
Coverage of HD within your state’s Essential Health Benefits
Under the Affordable Care Act a Health Insurance Exchange, or Marketplace, will operate. Each Marketplace will be run independently of the others, and will cater to the needs of the individual states. These Marketplaces will be operated by the state themselves, the federal government, or a combination of the two. The below map shows the Marketplace will be operating in each state.
In order for an insurance plan to be offered in a state, it must first meet the requirements of the Essential Health Benefits (EHB) package in that state. EHBs are a collection of health care services that insurance policies offered through State Exchanges are required to provide by 2014. At a minimum, Essential Health benefits must include services within the following 10 categories:
- 1. Ambulatory patient services
- 2. Emergency services
- 3. Hospitalization
- 4. Maternity and newborn care
- 5. Mental health and substance use disorder services, including behavioral health treatment
- 6. Prescription drugs
- 7. Rehabilitative and habilitative services and devices
- 8. Laboratory services
- 9. Preventive and wellness services and chronic disease management, and
- 10. Pediatric services, including oral and vision care
Advocacy Opportunity: Speak Up for HD!
In those states where the federal government will operate the Health Insurance Marketplace, there is still the opportunity to advocate. Your state will continue to have the opportunity to partner with the Federal government in the short term, and operate an independent Insurance Marketplace in the future. It is imperative that you continue advocating for a state-based Health Insurance Marketplace.
Governors and State Health Commissioners heavily influence the adoption of EHB packages. It is critical that we reach out to these individuals in order to guarantee that those with HD do not continue to fall through systematic cracks in coverage. Particularly, EHBs should promote meaningful mental health parity, address the coverage gaps that exist in small group plans, and mitigate the potential disparities in coverage among various state packages.
HDSA'S Advocacy Efforts
With the help of our network of advocates across the country, we have continued to influence and advocate for strong patient protections in the development of the Essential Health Benefits Packages, state-based Marketplaces, and in the development of national standards for Insurance Navigators. To read more about HDSA’s efforts in these areas, please see the comment letters we have submitted on these issues.
May 16, 2013: Comment on CMS-9955-P: Patient Protection and Affordable Care Act; Exchange Functions" Standards for Navigators and Non-Navigator Assistance Personnel (to Marilyn Tavenner) HDSA recommended the extension of conflict of interest protections to include lost insurance companies, subsidiaries and associates. We also recommended applying the same conflict of interest standards to both Navigators and non-Navigator assistance personnel in the exchanges. We also pushed a requirement that conflict of interest disclosures to be presented in plain language. We also advocated for the entire process to be more streamlined and more easily navigable as well as a role for patients and consumer advocates in order to protect those seeking insurance through this system.
February 18, 2013: Comment on CMS-2334-P: Medicaid, Children’s Health Insurance Programs, and Exchanges: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes for Medicaid and Exchange Eligibility Appeals and Other Provisions Related to Eligibility and Enrollment for Exchanges, Medicaid and CHIP, and Medicaid Premiums and Cost Sharing (to Marilyn Tavenner) HDSA urged HHS to create a more streamlined Medicaid appeals process and warned of the privacy issues that may come along with the electronic sharing system in the Medicaid enrollment process. We also reminded HHS of how necessary adequate mental health care is. Furthermore, we suggested that habilitative care be classified separately than rehabilitative care and that there should be a comprehensive federal standard for habilitative care.
May 11, 2012: Comment on CMS-9989-F: Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers (to Secretary Sebelius): HDSA emphasized the problems with a single medication being approved per therapeutic class for patients with degenerative diseases, like HD. We also encouraged a stronger voice for patients and consumers on the exchange governing boards and in the navigator program and a streamlined Medicaid eligibility determination process.
May 9, 2012: Comment on CMS-2349-F: Medicaid Program Eligibility Changes: HDSA expressed continued support for the expansion of state Medicaid programs to protect the most vulnerable patient populations.
January 31, 2012: Essential Health Benefits Bulletin Under the Affordable Care Act (To U.S. Department of Health and Human Services): HDSA emphasized the need for federal oversight of the Essential Benefits Package creation process to ensure that there are baseline requirements for mental health coverage, eliminating coverage gaps as much as possible, and reducing state disparities in coverage by having federal minimum standards. Additionally, the letter discusses the need for a diverse market of insurance providers. The comment also cautions that the ten categories defined by the ACA should be balanced and not weighted toward any category.
January 27, 2012: Essential Health Benefits Bulletin Under the Affordable Care Act (To Steven Larsen, Deputy Administrator & Director of the Center for Consumer Information and Insurance Oversight): HDSA emphasized the need for federal oversight of the Essential Benefits Package creation process to ensure that there are baseline requirements for mental health coverage, eliminating coverage gaps as much as possible, and reducing state disparities in coverage by having federal minimum standards.
September 28, 2011: Comment on CMS-9989-P: Establishment of Exchanges and Qualified Health Plans: HDSA weighed in to request added protections to the rule to ensure that the majority of funding is used for direct health care and to create transparency in the Exchange creation process.