WASHINGTON – Today, U.S. Sens. Mark R. Warner (D-VA) and Tina Smith (D-MN), joined by Sens. Amy Klobuchar (D-MN), Tammy Baldwin (D-WI), Michael Bennet (D-CO), Chris Murphy (D-CT), Bernie Sanders (I-VT), and Cory Booker (D-NJ), sent a letter to Department of Health and Human Services and Centers for Medicare & Medicaid Services (HHS/CMS) leadership urging them to review and formally report on the adequacy of the Affordable Care Act’s Essential Health Benefits (EHBs). The letter expressed the need for a review of telehealth flexibilities and the impact that scaling back these service options will have on those who rely on telehealth capabilities for treatment.

“As we begin to envision health care policies post-pandemic, we remain concerned telehealth services will be significantly pared back, hindering access to care for millions of Americans—especially those with complicated health conditions,” the Senators wrote.

When the Affordable Care Act was enacted, it required the Secretary of HHS to review EHBs and provide a report to Congress, and the public, that contains:

• An assessment of whether enrollees are facing any difficulty accessing needed services for reasons of coverage or cost;
• An assessment of whether the EHBs list needs to be modified or updated to account for changes in medical evidence or scientific advancement;
• Information on how EHBs will be modified to address any such gaps in access or changes in the evidence base;
• An assessment of the potential of additional or expanded benefits to increase costs and the interactions between the addition or expansion of benefits and reductions in existing benefits to meet actuarial limitations;

Despite this requirement, this formal review and report have never been undertaken or completed. The Senators stressed the need for this process in light of changes being made to care as the health care system shifts to a post-pandemic structure.

“We have heard from constituents who have concerns that coverage will start to vary based upon visit modality. For some specialized, complicated care—eating disorders, for example—it has always been challenging getting the most appropriate treatment covered, whether that’s because of parity or network issues,” the Senators continued. “We are concerned that modality will become one additional way barriers to treatment will be enacted, if arbitrary in-person requirements become one more way care is denied or delayed.”

The full text of the letter is available here and below:

Dear Secretary Becerra, Administrator Brooks-LaSure and Deputy Administrator Montz:

We thank you for your continued partnership in establishing and extending telehealth flexibilities to ensure Americans have access to vital health care services and supports over the course of the COVID-19 pandemic. As we begin to envision health care policies post-pandemic, we remain concerned telehealth services will be significantly pared back, hindering access to care for millions of Americans—especially those with complicated health conditions.

According to federal statute, it is incumbent upon the Secretary to periodically review insurance plan Essential Health Benefits (EHBs) and provide a public report to Congress that contains 1) an assessment of whether enrollees are facing difficulty accessing needed services for reasons of coverage or costs; 2) an assessment of whether plan benefits need to be modified or updated to account for changes in medical evidence or scientific advancement; 3) information on how plan benefits will be modified to address any such gaps or changes in the evidence base; and 4) an assessment of potential of additional or expanded benefits to increase costs and the interactions between the addition of benefits and reductions in existing benefits.

We believe after 12 years of the ACA it is important that EHBs be formally reviewed and the mandated report be issued to the public and Congress, especially as your Administration is committed to maintaining and further strengthening the law’s protections. We urge you to undertake such a review and report, and in addition we urge you to ensure that visit modality is not one of the “reasons of coverage” for which “enrollees are facing difficulty accessing needed services.”

We have heard from constituents who have concerns that coverage will start to vary based upon visit modality. For some specialized, complicated care—eating disorders, for example—it has always been challenging getting the most appropriate treatment covered, whether that’s because of parity or network issues. We are concerned that modality will become one additional way barriers to treatment will be enacted, if arbitrary in-person requirements become one more way care is denied or delayed.

The Department addressed a delay in completing such a report to Congress in its 2019 Notice of Benefit and Payment Parameter Final Rule, citing the need for further insurance market stabilization that the final rule would provide. Although we understand the difficulty of reviewing the markets as they continue to evolve, it is for that reason critical that the Administration review and report on EHBs so that we have an understanding of whether they continue to be adequate in an ever-evolving health care ecosystem. The health care system will not be the same after the COVID-19 pandemic, and this is an opportunity to renew our commitment to comprehensive, affordable and accessible health care coverage. We respectfully request this report be conducted and issued to Congress to inform future health policy to better serve Americans.

Thank you for your consideration, and we look forward to continuing to work with you on this very important issue.

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