Tag Archives: Bob Cosway

State-by-state variation in essential benefits

The Patient Protection and Affordable Care Act of 2010 (PPACA) introduced a concept called essential health benefits (EHB), 10 categories of healthcare services that plans operating in the state health insurance exchanges must cover when the exchanges come online on January 1, 2014. In December 2011, the U.S. Department of Health and Human Services (HHS) issued a bulletin providing guidance on EHB. HHS issued more regulations last week.

HHS delegated to the states the responsibility for determining the essential benefits in their states, with some constraints. This initial approach by HHS (for plan years 2014 and 2015) is intended to help states phase in the market reforms. It allows some flexibility for states in the initial decision about which specific services will be covered as essential, but limits the choice to what is currently covered by major plans in the state and nationally. States must define their essential benefits during the third quarter of 2012, with varying progress to date. This paper reviews the state employee benchmark plans and provides an illustration of possible variation in essential health benefits by state.

Effective PBM contracting

We have blogged before about possible increased transparency facing pharmacy benefit managers (PBMs), and about how changes in pharmaceutical average wholesale price will affect PBM contracts. Now a new article by Brian Anderson and Bob Cosway in Health Watch looks at some of the intricacies of effective PBM contracting from a plan sponsor’s perspective. What should employers and others that pay for healthcare look for in these contracts? What’s the best way to keep up with new drugs coming onto the market? How should pricing be set and kept current?