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

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 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.

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.

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 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.

AbbVie Inc., a large biopharmaceutical company, supports the review of Essential Health Benefits (EHB) and urges HHS to expand prescription drug coverage. They specifically advocate for closing regulatory gaps that allow plans to use "copay maximizers" and "alternative funding programs" to shift costs to patients, and they call for a robust federal floor for drug coverage.

The Coalition for 21st Century Medicine (C21) argues that biomarker tests should be classified as Essential Health Benefits (EHB) because they fall under the statutory laboratory services category. They contend that CMS should not allow these tests to be excluded from EHB for the purposes of state defrayal requirements or annual cost-sharing limitations, as doing so would hinder patient access to precision medicine.

Susan G. Komen, a nonprofit breast cancer organization, supports the RFI while urging CMS to ensure the Essential Health Benefits (EHB) framework protects patients from burdensome utilization management and covers critical services. They specifically advocate for prohibiting step therapy for metastatic cancer, closing loopholes for prescription drug coverage, ensuring oral parity for anti-cancer drugs, and including patient navigation, genetic counseling, and biomarker testing as EHBs.