Formal Comments on HHS Notice of Benefit and Payment Parameters for 2019

November 27, 2017

 

The Honorable Seema Verma

Administrator Centers for Medicare and Medicaid Services

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Washington, DC 20201

 

Re: Comments on HHS Notice of Benefit and Payment Parameters for 2019 Proposed Rule, RIN 0938-AT12

 

Dear Administrator Verma:

Partners for Better Care (“Partners”) appreciates the opportunity to comment on HHS Notice of Benefit and Payment Parameters for 2019 Proposed Rule. As a partnership of patient advocacy organizations and a diverse group of healthcare stakeholders representing more than 100 million people living with debilitating conditions nationwide – including Aetna, AIDS United, American Liver Foundation, Amputee Coalition, Autism Speaks, Christopher & Dana Reeve Foundation, The diaTribe Foundation, Genentech, Hemophilia Federation of America, Juvenile Diabetes Research Foundation, The MAGIC Foundation, Michael J Fox Foundation for Parkinson’s Research, National MS Society, National Organization for Rare Disorders, National Patient Advocate Foundation, Novo Nordisk, Obesity Action Coalition and United Cerebral Palsy – we provide the following comments regarding proposed payment parameters and provisions related to essential health benefits, out-of-pocket costs, medical loss ratio, and rate review.

Partners for Better Care advocates for the next generation of health care based on key principles of patient-centered quality care, availability, transparency and affordability. Our members advocate for those in need based on expert analysis, sophisticated services, and the experiences of the communities they represent. Together, Partners goes a step further and proposes solutions to improve health care for all Americans.

Partners appreciates efforts to strengthen the health insurance markets and, per our 2017 health care principles (attached), we are pleased to continue working with HHS to ensure health plans provide meaningful coverage and patients have access to quality care with enhanced affordability and reduced out-of-pocket costs. Specifically, Partners is concerned about possible changes to Essential Health Benefits (EHB), Medical Loss Ratio (MLR), rate review, standardized options, and out-of-pocket maximums.

Essential Health Benefits (EHB)

Partners is concerned that the proposed rule outlines several changes to EHB that could result in fewer benefits for patients in plan offerings. HHS proposes to provide states with additional flexibility in developing EHB benchmark plans for 2019 and beyond and outlines potential future directions for defining EHBs. In general, we do not oppose efforts to provide additional flexibility to states, however, we cannot support such efforts if they do not include safeguards to ensure that flexibility does not result in reducing beneficiary health benefits and access or increasing patient out of pocket cost-sharing. Further, we support the requirement set by statute that essential health benefits be similar to a typical employer plan operating in the state. Partners’ health care principles includes ensuring that health plans provide meaningful coverage and an appropriate scope of benefits. All plans – whether offered by employers or provided through the private or public market, including Medicare and Medicaid – must include coverage of preventive services and tools for management of chronic condition. Partners cannot support a process that would allow states to piece together limited benefits from separate existing plans to create a benchmark that has thinner coverage than actually exists in a state.

In addition, Partners seeks clarification regarding consideration of the development of a Federal default definition of essential health benefits, which could include the establishment of a national benchmark plan standard for prescription drugs. Partners requests that HHS provide additional information, including the goal and intended impact of this default definition and possible benchmark plan. In general, we are concerned that states opting for more generous coverage would be required to cover the cost that exceeds the Federal default. More specifically, Partners does not support this effort if the outcome will be the creation of more restrictive formularies for medically necessary prescriptions and lifesaving treatments, or otherwise shift a greater proportion of medication costs to patients, subsequently hindering access to care

Medical Loss Ratio

HHS is proposing changes to the Medical Loss Ratio adjustment process and criteria, reporting requirements and calculations. Currently, small group plans must spend at least 80% of premium dollars on medical care, large group plans must spend at least 85% of premium dollars on medical care, and insurers must provide rebates if they fail to meet the MLR standard. While we appreciate HHS working to increase issuer participation and market competition, Partners is concerned that allowing states to request adjustment to the MLR based on a reasonable likelihood that an adjustment will help stabilize the individual market in that state is too broad a standard. We believe insurers should continue to be required to show calculations and states should continue to consider how MLR changes will impact patients’ coverage, premiums, benefits, out-of-pocket costs, and provide detailed reports on decision-making, as well as providing evidence that changes will increase market competition.

Rate Review

Partners believes that patients should have limited cost-sharing, with predictable and affordable total out-of-pocket costs, including deductibles, co-pays, co-insurance, premium costs or contributions to premiums across care settings, and HHS’s proposal to raise from 10% to 15% the reasonable rate increase threshold is of concern. Further, we have urged HHS to enhance affordability and reduce out-of-pocket costs by maintaining subsidies and seeking new, creative mechanisms to limit cost shifting to patients. In this instance, we support review for rate increases at the existing level of 10% and ask that HHS not create exemptions for populations such as student health insurance coverage.

Standardized Options

While we support incentives for issuers to offer coverage with innovative plan designs, Partners urges HHS to continue supporting the standardized plan options and the meaningful difference standard. Providing consumers with tools to better understand coverage options and how to compare plans is critical. Partners has specifically supported standardized plan options that exempt cost-sharing for prescription drugs from the deductible, and we continue to support that design. Many individuals and families coping with a chronic or life-threatening condition live paycheck to paycheck, leading them to question when their health is “bad enough” to justify the costs of treatment. Clear information to assist with understanding sometimes complicated insurance plans designs is one way to help patients seek needed care, especially after coverage has already been purchased. Patients can have difficulty getting information or understanding plan coverage and expected out-of-pocket costs, including details about deductibles and formularies, which can become a barrier to seeking treatment. We support efforts to facilitate clarity in consumer choices, which allows patients to take control of managing their health and reducing costly emergency health needs.

Out-of-Pocket Maximums

Partners is also concerned that the new rule could adjust the limit for individual coverage to $7,900 and $15,800 for family coverage, which would be the highest single year increase since the Maximum Out-of-Pocket was created in 2014. Partners supports enhancing affordability and reducing out-of-pocket costs, including ensuring that appropriate payments are credited to out-of-pocket limits for needed treatments and services. Health care costs have continued to rise, resulting in patients having to pay significantly more out-of-pocket for their health care. Patients have seen these out-of-pocket costs increase in the form of premiums, deductibles, and cost-sharing for most health care services. These varying out-of-pocket costs, combined with a lack of information about costs and what contributes to them, create a situation of unpredictable and unmanageable costs, which negatively impacts both patients’ ability to access needed care and their health care outcomes.

Partners and its members believe that every American should have access to affordable, high-quality, patient-centered coverage in 2017 and beyond. We look forward to working with HHS and leaders on both sides of the aisle to ensure that changes to the health system work for all Americans, especially those living with debilitating conditions.

If you have any questions or need any further information relating to our comments, please do not hesitate to contact me at mrichards@partnersforbettercare.org.

Sincerely,

Mary Richards

Executive Director

Partners for Better Care

2017 Health Care Principles

Partners for Better Care (“Partners”) is a coalition led by patients and their allies advocating for the next generation of healthcare. Our members are patient advocacy organizations and a diverse group of healthcare stakeholders, including industry and payers, who are working together with policymakers to develop the best solutions to today’s healthcare challenges. Partners represents more than 100 million patients living with a wide range of chronic and acute conditions, and we believe that Americans should have access to the necessary care to improve their health and the health of their families.

With the strong backbone of our nonpartisan Patient Charter, Partners’ members developed 2017 health care principles. As experts on patient-centered care, Partners and its members are proud to serve as a resource to policymakers and thought leaders. We remain committed to working with Congress, the Administration and other healthcare stakeholders to advance the following priorities:

  • Ensure health plans provide meaningful coverage and an appropriate scope of benefits. All plans – whether offered by employers or provided through the private or public market, including Medicare and Medicaid— must include coverage of preventive services, tools for management of chronic conditions, coordinated care and specialist care, innovative therapies and technologies, and mental health services.
  • Ensure access to quality care by preventing pre-existing conditions and rating restrictions, as well as maintaining diverse risk pools and restricting plans from excluding or limiting coverage for one type of patient or condition. We must ensure that all individuals, particularly those with chronic conditions, cannot be denied coverage, charged unreasonable premiums or denied renewability.
  • Enhance affordability and reduce out-of-pocket costs by maintaining subsidies and seeking new, creative mechanisms to limit cost shifting to patients.
  • Maintain the ban on annual and lifetime limits to ensure patients and their families receive needed medical care throughout the year and over a lifetime. For patients, annual and lifetime caps on treatments, therapies, and other care can contribute to significant complications, including limiting the ability to work.
  • Continue to allow young adults to stay on their parents’ plan through age 26, which makes health insurance easier to obtain and more affordable for all. Young people living with debilitating conditions need consistent, affordable and accessible treatments and therapies.
  • Ensure quality Medicare and Medicaid coverage so our nation’s seniors, disabled and low-income individuals in all states have access to the coverage, services and care they need.
  • Encourage value, quality and cost innovations through the development of patient-centered approaches that incorporate the patient experience as well as data on policy development and value strategies.

Partners and its members believe that every American should have access to affordable, high-quality, patient-centered coverage in 2017 and beyond. We look forward to working with other healthcare stakeholders, Congress, the Administration and leaders on both sides of the aisle to ensure that changes to the health system work for all Americans, especially those living with debilitating conditions.