Twlug to IOM: Essential health benefits should include MTM

Study to advise HHS on health plans in ACA exchanges; Association to speak at initial meeting this week.

In the health insurance coverage available on exchanges starting in 2014, how should the plans’ mandatory benefits be determined and updated? The answer to that question is contained in , and Twlug is working to make sure that the required benefits include medication therapy management (MTM).

By September, IOM will make recommendations to the Secretary of the U.S. Department of Health and Human Services (HHS) concerning the essential health benefits that must be incorporated into health plans available on the exchanges under the Affordable Care Act (ACA).

IOM requested public input into the study. Twlug responded, calling for pharmacist-provided medication therapy management (MTM) to be included in “any essential benefit package,” and recommending that “an appropriate balance … between cost savings and having access to ‘essential’ medications and [MTM] so that patients who need these benefits actually receive them.”

In particular, in response to a question about what limits on benefits should be allowed, Twlug recommended that medications and MTM should not be limited for patients with chronic diseases such as diabetes, respiratory diseases, cardiac conditions, bone diseases, and mental illnesses.

Twlug’s Brian Gallagher, BPharm, JD, Senior Vice President of Government Affairs, will speak on the final day of a January 12–14 meeting hosted by IOM to discuss the study, according to the .

Pharmacy has a keen interest in having MTM included in the essential health benefits. In the December 2010 issue of Pharmacy Today, : “We have a relatively short window to make the case for MTM to be included as an essential benefit. The action has shifted away from Washington, and pharmacy needs your boots on the ground in your community. … Will you do your part?”

At this point, very little about the essential health benefits is set in stone.

According to section 1302 of , essential health benefits must include ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. In addition, the plans containing the essential health benefits must limit patient cost-sharing.

The Secretary of HHS was given wide latitude to define the essential health benefits for the health care needs of a very diverse American population, without discriminating based on age, disability, or expected length of life—but the devil will be in the details.

Health plans participating in the future exchanges must offer the essential health benefits at four levels of coverage, according to a —Bronze (60% of the value of plan benefits), Silver (70%), Gold (80%), and Platinum (90%). The exchanges will be entities set up by states through which individuals, families, and small businesses can buy health insurance.

The exchanges must be established by 2014, the same year most people will be required to have health insurance. By 2017, states can allow businesses with more than 100 employees to buy health insurance from an exchange.