Essential Health Benefits Package
The Tennessee Disability Coalition has submitted to Commissioner McPeak of the TN Department of Commerce and Insurance the following comments on an Essential Health Benefits Package to be implemented as part of the Patient Protection and Affordable Care Act in the state of Tennessee:
Our organization represents more than 45 member agencies statewide and works with families and individuals to advocate for effective disability public policy. We believe that for healthcare reform to work for individuals with disabilities the Affordable Care Act’s mandated benefit categories and non-discrimination provisions must be the foundation of the essential health benefits package on which Tennesseans will depend starting in 2014.
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Comprehensive coverage is critical for our community. Current state mandates passed by the General Assembly serve as critical protections for Tennesseans and should be integrated into the essential health benefits package. Individuals with disabilities are a diverse population with health care needs that follow low-incidence diagnoses and chronic illnesses. Restrictive coverage definitions, impediments to early intervention, and arbitrary limitations on benefits unfairly restrict access to services that enable people with disabilities to remain in or enter the workforce and live independently.
Early childhood screening identifies health and developmental needs of young children. Early identification is critical to the well-being of children and their families. Wellness and prevention services have significant and often sizeable benefits to children, circumvent greater lifelong costs, and result in improved outcomes through adolescence, the transition to adulthood and even decades after the cessation of services.
Rehabilitation services are crucial to improving a beneficiaries’ ability to function, participate in daily living, maintain productivity and improve the quality of their health outcomes. Psychiatric rehabilitation services are central to recovery and resiliency for adults and children living with severe mental illness. These services are also vital in the prevention of secondary disabilities. Provision of essential rehabilitation services without arbitrary restrictions in scope and quantity result in effective treatment, amelioration of health conditions and reduced hospital and emergency room costs.
Tennessee’s benchmark plan should include habilitation coverage. Habilitation services help individuals with disabilities achieve independence and good health. These services enhance quality of life and enable many to live in more integrated home and community based settings rather than receive care in a much more costly hospital, nursing or intermediate care facility.
Strong and meaningful prescription drug benefits are critical for people living with a disability, chronic health condition or mental illness. Across the broad range of diagnosis, pharmacological interventions are often a vital element of treatment. The prescription benefits of Medicare Part D provide a model for Tennessee’s essential health benefits platform. This plan must have adequate formularies and flexibility to meet the unique needs of individuals with disabilities.
Tennessee’s benchmark plan must comply with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) and with consumer protections outlined in Section 1302(b)(4)(A-D) of the Patient Protection and Affordable Care Act. If mental health and substance abuse benefits are not provided at parity in the plan that Tennessee chooses, benefits from another plan must be substituted.
Access to durable medical equipment is a cornerstone of effective healthcare for individuals with disabilities. Wheelchairs, lifts, oxygen tents and glucose monitors are examples of durable medical equipment which treat medical conditions and improve the mobility of Tennesseans each day. Purchase or rental of durable medical equipment, supplies and ancillary services to make most effective use of the equipment must be covered in a benchmark plan. Coverage limits on items such as the prosthetic which allows a man to walk into work each morning and hearing aids which bring the sound of a mother’s voice to her daughter are an expensive mistake.
Individuals with disabilities have long faced discrimination in health care and insurance coverage. The Patient Protection and Affordable Care Act offers the hope of equivalent coverage. It is critical that the Essential Health Benefits Plan implemented in our state operates as a minimum standard that protects access and affordability of health care for Tennesseans with disabilities.
The EHB benchmark should prohibit insurance companies from limiting access to medically necessary health care services, especially for individuals with higher cost chronic conditions through dollar or visit limits on essential services, condition-specific restrictions, excessive cost-sharing, and/or unduly burdensome utilization management and prior authorization requirements. Such practices penalize people with disabilities and other chronic conditions who rely upon routine medical visits to stay healthy and prevent disease progression, or secondary or tertiary disabilities.
We endeavor you to take into consideration the “essential health benefits” that evidence and experience have identified as priorities to citizens with disabilities and which we have listed above. As the Department moves forward toward a decision, we would appreciate the opportunity to review the specific benefit provisions of the potential benchmark plans. We want to work with the Department to design a benchmark that meets the needs of all people in Tennessee.