AIDS Institute: Biden Administration Makes Coverage Improvements in Finalized Rule

WASHINGTON, April 5 -- The AIDS Institute issued the following news release:

The United States Department of Health and Human Services (HHS) released the much-anticipated final 2025 Notice of Benefit and Payment Parameters (NBPP) last night, the annual rule governing health insurance plans subject to the Affordable Care Act (ACA). The rule makes important improvements in coverage but stops short of addressing crucial cost-sharing protections for people living with chronic illness.

Among the improvements important to people living with and at risk of HIV and viral hepatitis, the rule:

* Clarifies that all prescription drugs covered by an individual and small group market health insurance plan must be included in protections for essential health benefits (EHB). The Administration also announced that it intends to issue a rule soon clarifying that this policy also applies to large group and self-insured health plans. This step will address gaming in the health insurance market related to coverage of high-cost specialty medications and ensure that people who use medically necessary drugs covered by their plans will have the benefit of cost- sharing protections intended by the ACA.

* Allows marketplace insurance plans to provide coverage for adult dental health services. Oral health care is particularly important for people living with HIV, who are at greater risk for infections and for whom an oral health infection can be particularly dangerous.

* Requires inclusion of a patient representative on Pharmacy & Therapeutics (P&T) Committees, which will help bring an experienced patient voice to the formulary and coverage decisions made by these committees.

"It is heartening to see these improvements, which will help ensure that health insurance coverage meets the needs of the people living with chronic illness," said Stephanie Hengst, manager for policy and research. "We are especially pleased to see that the Administration will be addressing the "EHB loophole," which will help staunch the erosion of employer health plan coverage for prescription drugs. We urge the agencies to move quickly to issue and finalize that new rule."

We are disappointed to see that HHS did not use the 2025 NBPP to address a key issue for patient out-of-pocket costs: copay accumulator adjustment policies. A court decision in 2023 reinstated a 2020 NBPP provision restricting insurers' and PBMs' ability to pocket copay assistance payments made on behalf of enrollees without counting those payments toward the enrollees' cost-sharing obligation for the year. Patient groups - including The AIDS Institute - urged HHS to use the 2025 NBPP to clarify for insurers and PBMs that it would enforce the 2020 rule. Inclusion of this provision could have helped the Administration make progress on its goal of making healthcare more affordable and accessible for the most vulnerable patients.

The AIDS Institute appreciates the direction HHS and the Biden Administration is moving, but continues to encourage officials to go further by requiring insurers and PBMs to count copay assistance toward an enrollee's cost-sharing requirements. These policy changes together will have the most immediate and meaningful impact for patients.

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The AIDS Institute is a national, nonpartisan, nonprofit organization that promotes action for social change through public policy, research, advocacy and education.

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Original text here: https://www.theaidsinstitute.org/press-releases-2024/biden-administration-makes-coverage-improvements-in-finalized-rule