Request for Information: Comprehensive Review of the Essential Health Benefits Framework and Typical Employer Plan Standard

The Connected Health Initiative (CHI) supports CMS's review of the Essential Health Benefits (EHB) framework, urging the agency to ensure the framework remains technology-neutral and reflects current employer plan coverage of digital health tools. They advocate for including connected health benefits—such as telehealth, remote monitoring, and digital therapeutics—within the EHB by emphasizing their clinical benefits and cost-saving potential.

The American Academy of Pediatric Dentistry (AAPD) supports the continued recognition of pediatric dental services as an Essential Health Benefit (EHB) and advocates for strengthening its implementation. They urge CMS to ensure consistency across states, align benefits with clinical guidelines, and close regulatory loopholes that allow children to be left without dental coverage.

The Wright Center, a safety-net healthcare provider and medical educator, supports the preservation of comprehensive primary care and preventive services within the Essential Health Benefits framework. They argue for increased reimbursement for nutrition services, behavioral health integration, and longitudinal care coordination to improve health outcomes and long-term affordability.

Gilead Sciences, Inc. supports the review of the Essential Health Benefits (EHB) framework and advocates for mandatory coverage of all FDA-approved PrEP medications with no cost-sharing. They also recommend broadening prescription drug coverage, prohibiting copay accumulators and maximizers, and ensuring that innovative therapies like CAR T are included in EHB requirements.

The National Health Council (NHC) supports the CMS review of the Essential Health Benefits (EHB) framework, urging the agency to maintain EHB as a comprehensive patient protection floor. They recommend modernizing the framework to reflect current clinical evidence and patient needs while ensuring that changes do not narrow access to care or shift costs to patients.

UnitedHealthcare supports the CMS review of the Essential Health Benefits (EHB) framework, emphasizing the need to maintain alignment with typical employer-sponsored coverage to ensure affordability and market stability. The company advocates for using current data (including self-funded plans) to define "typicality," promoting consistency across states to reduce administrative burdens, and ensuring any updates are phased in with sufficient lead time.

The American College of Gastroenterology (ACG) supports the review of the Essential Health Benefits (EHB) framework and urges CMS to clarify that follow-up surveillance colonoscopies for asymptomatic patients with a history of polyps should be classified as "screening" rather than "diagnostic." They argue that this change is clinically appropriate, consistent with USPSTF recommendations, and would remove cost-sharing barriers for patients at risk of colorectal cancer.

The American Lung Association supports the existing Essential Health Benefits (EHB) framework and urges HHS to strengthen patient protections rather than reducing coverage. They recommend establishing a regular, evidence-based review process for EHB standards and improving transparency and enforcement to ensure patients with chronic respiratory diseases have consistent access to necessary treatments.

The American Cancer Society Cancer Action Network (ACS CAN) supports a comprehensive review of the Essential Health Benefits (EHB) framework to ensure it provides sufficient coverage for serious illnesses like cancer. They advocate for specific improvements, including the inclusion of biomarker testing in laboratory services, requiring plans to cover at least two drugs per USP category, and ensuring robust federal and state oversight of EHB protections.

The National Pharmaceutical Council (NPC) supports the comprehensive review of the Essential Health Benefits (EHB) framework and advocates for specific improvements. They recommend prohibiting cost-management strategies like accumulators and maximizers, ensuring robust coverage for innovative brand and generic drugs, and updating drug classification systems to better reflect modern clinical guidelines.