Manatt Professional Discusses Process for Determining Essential Benefits

“Essential Benefits Still Being Debated”
Managed Healthcare Executive 

June 1, 2011 – Manatt’s Ian Spatz, a senior advisor in the firm’s Healthcare division, was interviewed by Managed Healthcare Executive on how the U.S. Department of Health and Human Services (HHS) will determine the essential benefits that all health plan products are to offer through state health insurance exchanges.

“It’s the basis for determining what it means to have health coverage or not to have health coverage,” Spatz said in regard to HHS’s task to determine the qualifications of essential health benefits. “Especially if you are going to be in a health benefit exchange and there’s a subsidy, what’s the government going to be paying to subsidize it? There is almost no more important issue in healthcare than what it means to be covered.”

Spatz thinks the federal government will look at what states consider essential, but it won’t provide a definition that is specific. He expects the issue will move from the federal government to the states, and possibly back to the federal government to be finalized.

“States and health plans can be working to get more definition so there isn’t a big scramble in 2013 as they are trying to approve plans,” he suggests. “Now is the time to speak up. States have things they routinely mandate they want to see included.”

Spatz continues, “I think this will be a good process. Some of those micro-level decisions can be made at the state level, and there can be some variation among the states. At the same time, where major issues become identified, there is a process for getting resolution at the national level. It’s analogous to what Medicare does today in allowing local coverage decisions to be made by local carriers to allow experimentation and variance. At the same time, there is a national process where we feel the need for uniformity.”