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AAMC Comments on Essential Health Benefits Proposed Rule

December 28, 2012—The AAMC submitted a Dec. 26 comment letter to the Centers for Medicare and Medicaid Services (CMS) on a proposed rule for Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation of health insurance exchanges (Exchanges). The AAMC’s comments on essential health benefits (EHB) standards focus on annual limitations on cost-sharing and deductibles, updating essential health benefits, oversight and enforcement, and prescription drug benefits. 

The AAMC’s comment letter includes the following recommendations:

  • That CMS establish annual limitations for out-of-network services and/or strengthen network adequacy requirements.  If necessary health care services or specialists are not available in-network, out-of-network care should count toward the annual limit to avoid a policy that may become a barrier to timely access to medically necessary care;
  • Due to rapid and ever-changing standards of care, there must be a process for updating the EHB package frequently enough to provide adequate coverage of new treatments that become the standard of care;
  • Encouraging CMS to assume a more active role in monitoring and enforcement to ensure that there is strong national policy to guide the application and enforcement of EHB requirements and in monitoring and identifying discriminatory benefit designs; and
  • Supporting the CMS proposal for more comprehensive prescription drug benefit requirements than those in the December 2011 Department of Health and Human Services (HHS) bulletin on EHB, and encouraged CMS to finalize its proposal. 

The proposed rule was released Nov. 26 and is a step in implementing Exchanges, mandated by the Affordable Care Act (ACA, P.L. 111-148 and P.L. 111-152) to begin in 2014.  CMS had previously solicited input on EHB in a bulletin released last winter [see Washington Highlights, Feb. 3].


Jane Eilbacher
Policy and Regulatory Specialist
Telephone: 202-828-0896


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Jason Kleinman
Sr. Legislative Analyst, Govt. Relations
Telephone: 202-903-0806