ACR Says Final Rule on EHB Benchmark Plans Could Reduce Access to Biologics

This week, the American College of Rheumatology (ACR) raised concerns that CMS’ final 2019 Payment Notice Rule, which provides states with increased flexibility to determine which plan options they can select as Essential Health Benefit- (EHB) benchmark plans and select their own sets of benefits, could seriously jeopardize care for patients with inflammatory diseases.

David Daikh, MD, PhD, president of ACR, said in a statement, “While we are pleased to see that [CMS] is using this rule to reduce regulatory burdens and promote drug price transparency, we are disappointed that the agency did not heed the advice of the ACR and other health groups regarding Essential Health Benefits coverage.” Daikh added that “It is absolutely critical that people living with rheumatic diseases are able to access insurance coverage on the federal exchanges without having to worry about whether the treatments they need to manage their conditions will be covered.”

In its November 2017 comments to CMS, ACR warned that any weakening or removal of EHB requirements could lead to only 1 drug per class to be covered under benchmark plans, and could undermine providers’ clinical decisions about which biologic drug to use in treating rheumatic diseases. In its comment letter, ACR explained that the decision to treat a patient with 1 biologic rather than another takes into consideration a variety of factors, from the patient’s age, diagnosis, and comorbidities to access to transportation, antibody status, and concomitant medications.

“Entities such as insurers or states should not be able to determine the treatment of the patient, nor should they mandate use of [1] therapy over another,” said ACR’s letter.

Separately, ACR praised CMS for its choice not to move forward with a prior plan to designate Children’s Health Insurance Program buy-in programs that provided coverage identical to state CHIP programs as “minimum essential coverage” without first being assessed via an application process. ACR had urged CMS to abandon its proposal, saying that it would leave children with rheumatic diseases in “medical limbo” without the guarantee that the coverage provided under these programs would in fact be the same.