The report outlines three categories of patient protections:
• Benefit designs that avoid discrimination, encourage equal access and provide clear guidance for plan members;
These include cost-sharing protections, including “requirements for plans to disclose to all prospective and current members the deductible, co-payment and co-insurance amounts applicable to in-network and out-of-network covered services” and “oversight mechanisms to ensure that states are reviewing plan benefit design to determine that cost-sharing is neither unfair nor discriminatory.” The council also recommends that the benefits package require plan cooperation and coordination when people switch enrollment between plans or between coverage, and provide for oversight of plan benefit design to avoid discrimination caused by the unfair use of such management techniques as step therapy;
• Support for patient care and decision-making. These include care coordination and strong navigator programs to inform people of their rights and options; and
• Enforcement tools for individual and state and federal authorities to ensure that people are getting access to care. These include strong federal and state oversight and robust grievance and appeals procedures for beneficiaries.
“For [essential health benefits] and qualified health plans to operate as intended,” the Council wrote, “the federal government must supervise states as they oversee plans operating in their states at the same time that individuals should hold their plans accountable for coverage policies.”