THE ESSENTIAL ISSUES

Essential Health Benefits

People with serious and chronic health conditions need access to a comprehensive set of health benefits and services, including health care specialists and prescription medications. The ACA helps guarantee such access by requiring each Qualified Health Plan to offer ten Essential Health Benefits.

To ensure that the Essential Health Benefits meet the unique needs of every beneficiary, I Am Essential advocates for a full range of benefits, including broad prescription formularies that allow for the addition of new innovative medications. To learn more about Essential Health Benefits, read the coalition letters and press releases on the issue.

Out-of-pocket costs

Affordable out-of-pocket costs are critical to ensuring access to care and treatment, especially for people with serious and chronic health conditions who may need multiple medications and providers to maintain their health.

One of I Am Essential's central goals is to ensure the ACA's out-of-pocket cost protections are enforced and strengthened. We advocate that both the U.S. Department of Health & Human Services and states protect beneficiaries from high cost-sharing. Possible solutions include implementing standard benefit design and co-pay limits, maintaining out-of-pocket maximums, exempting prescription drugs from deductibles, and using co-pays instead of co-insurance.

Transparency

In order for beneficiaries to select the plans that best meet their individual health care needs and be able to use their coverage effectively, they must have access to easy-to-understand, detailed, and up-to-date information about plan benefits, formularies, provider networks, and cost-sharing. Co-insurance equates to a total lack of transparency because beneficiaries cannot determine their out-of-pocket costs for a prescription or service in advance. If a plan does use co-insurance, at a minimum, beneficiaries should be able to calculate patient cost-sharing in dollar terms.

For more information and to learn more about how the coalition has engaged in advocating for increased transparency, read the coalition letters and statements on the issue.

Non-discrimination

Although recent progress has been made in prohibiting plans from using discriminatory benefit designs and marketing practices, more work needs to be done to define discriminatory practices in plan benefit design for all beneficiaries. Therefore, among other things, I Am Essential urges HHS to strengthen patient protections by preventing plans from placing all or nearly all medications to treat a certain condition on the highest cost-sharing tier; not covering certain medications or not following treatment guidelines; imposing excessive medication management tools such as unreasonable prior authorization, step-therapy requirements, and switching medications midyear; charging high cost-sharing to beneficiaries with chronic or serious conditions; and having narrow and exclusionary provider networks.

For more information on discriminatory practices and plan design, read the coalition letters and statements.