The move by the U.S. Department of Health and Human Services (HHS) to let states set their own definitions of "essential health benefits" covered by plans in upcoming health insurance exchanges spells opportunity for pharmacists, according to the American Pharmacists Association (APhA).


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APhA: States could make MTM an 'essential health benefit'

January 4th, 2012

WASHINGTON – The move by the U.S. Department of Health and Human Services (HHS) to let states set their own definitions of "essential health benefits" covered by plans in upcoming health insurance exchanges spells opportunity for pharmacists, according to the American Pharmacists Association (APhA).

Pointing to a bulletin issued last month by HHS, APhA reported that the pharmacy industry has a good chance to get pharmacist-led medication therapy management (MTM) included as an essential benefit in plans slated to become available via state health insurance launching in 2014, as called for under the Affordable Care Act health care reform law.

APhA noted that last year it had pushed to have MTM designated as an essential benefit on a national level by providing input to the Institute of Medicine (IOM), which gave HSS recommendations on essential health benefits to be included in the insurance plans. Though that effort fell short, HHS' latest proposal brings renewed hope for pharmacists, according to the association.

"The bad news is that there's not one national standard. The good news is that [pharmacy has] 50 chances to try to get MTM included," Brian Gallagher, APhA's senior vice president of government affairs, stated in an article on the APhA website. "We're confident that once one state implements robust MTM programs, [MTM] will expand to other states as they see how much money it saves."

Rebecca Snead, executive vice president and chief executive officer of the National Alliance of State Pharmacy Associations, commented in the APhA article that defining "essential benefits" gives the pharmacy sector the latitude to make MTM a core element of care. "It is possible to establish a definitive role for pharmacists as part of the health care team in the management of patients with chronic disease," she stated. "It is more critical than ever before that state pharmacy associations have strong grassroots support for their advocacy efforts."

Under the Affordable Care Act, health insurance plans offered in the individual and small group markets, both inside and outside the Affordable Insurance Exchanges, must include a comprehensive package of items and services, dubbed "essential health benefits."

HHS' proposal in its Dec. 16 bulletin aims to give states the flexibility to pick a health plan to set the benchmark for the items and services deemed as essential benefits. As a benchmark, states would select one of the following: one of the three largest small group plans in the state; one of the three largest state employee health plans; one of the three largest federal employee health plan options; or the largest HMO plan in the state's commercial market.

According to HHS, essential health benefits must include items and services in at least the following 10 categories: ambulatory patient services, emergency services, hospitalization, prescription drugs, maternity and newborn care, mental health and substance use disorder services (including behavioral health treatment), rehabilitative and habilitative services and devices, laboratory services, preventive/wellness services and chronic disease management, and pediatric services (including oral and vision care).

HHS is seeking public comment on the proposal by Jan. 31.

"More than 30 million Americans who newly have insurance coverage in 2014 will have a comprehensive benefit package," Sherry Glied, assistant secretary for planning and evaluation at HHS, stated in the department's bulletin. "In addition to assuring comprehensive coverage for the newly insured, many millions of Americans buying their own insurance today will gain valuable new coverage, including more than 8 million Americans who currently do not have maternity coverage, and more than 1 million who will gain prescription drug coverage."

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