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

Michelle Marciniak, representing Let Kids Hear and Let California Kids Hear, urges CMS to issue a sub-regulatory clarification to include medically necessary pediatric hearing aids and BAHA softbands within the "pediatric services" category of the ACA Essential Health Benefits. The organization argues that closing this coverage gap is a developmental necessity for children with hearing loss and can be achieved without new legislation or state defrayal.

Kentucky Voices for Health supports the comprehensive review of the Essential Health Benefits (EHB) framework, advocating for stronger federal minimum standards that serve as a floor rather than a ceiling. They argue that CMS should prioritize consumer affordability, transparency in state benchmark selection, and a regular, evidence-based review process to ensure meaningful access to care.

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 Diabetes Patient Advocacy Coalition (DPAC) and the Diabetes Leadership Council (DLC) support a robust Essential Health Benefits (EHB) framework that aligns with clinical standards of care for diabetes. They argue that comprehensive coverage is necessary for patient health and that CMS should focus on addressing cost barriers and PBM practices rather than reducing the scope of EHB requirements.

Consumers for Quality Care (CQC), a coalition of patient advocates, urges CMS to preserve and strengthen the existing Essential Health Benefits (EHB) framework. They argue that weakening these standards would increase financial risks for families, reduce the value of coverage, and disproportionately harm vulnerable populations with chronic illnesses.

Families USA, a nonpartisan health care consumer advocacy organization, supports the continued use of the benchmark plan approach to define Essential Health Benefits (EHBs) and opposes using actuarial value as a replacement. They urge CMS to require states to regularly review and update their EHB benchmark plans to ensure they reflect the scope of benefits provided by typical employer plans.

The California Association of Health Plans (CAHP) supports the CMS review of the Essential Health Benefits (EHB) framework, provided that any changes prioritize affordability, preserve state flexibility, and maintain market stability. They advocate for transparent benchmark plan update processes and request that CMS consider the impact of state-specific benefit mandates on overall costs and utilization.

Plume Clinic, a telehealth medical provider for the transgender and non-binary community, supports a comprehensive review of the Essential Health Benefits (EHB) framework. They argue that gender-affirming care is cost-effective, medically necessary, and should be included in the EHB, specifically urging CMS to remove previous prohibitions on such coverage.

The Coalition to Preserve Rehabilitation (CPR) and the Habilitation Benefits (HAB) Coalition submitted joint comments urging CMS to preserve the current Essential Health Benefits (EHB) framework. They argue that the current framework provides critical protections for individuals with disabilities and that any changes weakening these benefits would undermine congressional intent and previous policy successes.

The National Association of Insurance Commissioners (NAIC) supports the current framework for defining Essential Health Benefits (EHB) while advocating for state flexibility and the preservation of existing state applications. They urge CMS to collaborate with states to complete pending updates, utilize actuarial expertise, and prioritize compliance-based reviews over benefit-by-benefit analysis.