Essential Questions for Essential Benefits - Pharmaceutical Executive


Essential Questions for Essential Benefits

Pharmaceutical Executive

Whose Bottom Line?

As previously noted, the CCIIO bulletin suggests that the EHB will focus on what is considered a "covered service" and not a plan's cost-sharing feature. Hence, issues of deductibles, copayments, and coinsurance are expected to relate to the actuarial value of a plan based on the "metal level" of coverage (bronze, silver, gold, and platinum). Here, states may play a role in the review of such analyses that can likewise relate to medication cost-sharing. While issues of copayments (a flat payment per prescription) versus coinsurance (a percent charge of prescription cost) will be important to consider, it appears these costs will be limited to overall out-of-pocket caps for the program—or at least they should be. Attention to this detail is important to assure patients on costly and multiple medications are protected.

Ultimately, states will influence essential medication coverage via their exchange or department of insurance by virtue of the EHB benchmark they select and their anticipated review of actuarial equivalence. In addition, state determination of which health plans are allowed into an exchange will have an indirect influence on the application of these provisions by virtue of the coverage choices plans make.

Collaboration is Key

As all of these issues are addressed, engagement with key government decision-makers is essential. Certainly, input to the CCIIO guidance by the Jan. 31 deadline and subsequent related regulations will be a critical step as federal guidelines are developed. Given the importance of benchmark selection and plan offerings in a state exchange or state insurance exchange boards, staff and advisory committees should also be considered for appropriate interaction. Of course, such interactions with the exchanges will largely be driven by the degree to which states actually establish such entities.

In October 2011, the National Conference of State Legislators (NCSL) reported that 14 states have enacted exchange legislation in 2010 or 2011, with only Massachusetts and Utah passing exchange laws prior to the enactment of the ACA. At the same time, NCSL reported that 16 states failed to pass such a law in 2011. As the deadline for exchange creation approaches, pressure will mount for state action. Failure by states to establish such an entity will result in the federal government creation of a state exchange, altering the eventual focus of input.

Within the states, a growing number are completing their exchange planning reports, which illustrates the challenges ahead for ACA implementation. Many of the emerging details articulate the importance of the organization of the exchange and its board membership composition. Establishing a balance of interests should be an important first step in making sure no single perspective dominates the direction of key decisions. In addition, many states call for the creation of advisory committees that may influence exchange decisions and more directly address clinical, coverage and cost decisions.

Following the creation of the exchange boards, a key development to watch for is the drafting of state exchange plans of action. While not universally included in emerging state legislation, the development of such plans can be expected due to requirements for an "exchange plan" as called for in current draft regulations. Such plans may offer direction on the issues previously discussed above, including the approach for the selection of the EHB benchmark.

There are a number of factors that will influence the final determination of essential medication coverage, including EHB and cost-sharing provisions defined at the federal and state level. The decisions made in the coming months and years will have profound implications for medication coverage and covered patients for perhaps a generation. Now is the time for biopharmaceutical companies and others concerned about medication coverage to prepare and provide their perspectives to key decision-makers in order to assure that patients have access to the care they need.

Christopher J. Piazza, RPh, is Principal at Lighthouse Health Policy Consultants. He can be reaced at


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