ACR: CMS Rule on Essential Health Benefit Coverage Could Harm Patient Access to Rheumatology Care


The 2019 Benefit and Payment Parameters final rule allows states to select their own Essential Health Benefits benchmark plans.

Rheumatology leaders have expressed concern that the Centers for Medicare and Medicaid Services’ (CMS) final ruling on Essential Health Benefit (EHB) coverage could harm patient access to care, according to a statement released by the American College of Rheumatology (ACR).

In the statement, the ACR addresses the 2019 Benefit and Payment Parameters final rule, which allows states to select their own EHB benchmark plans on federal health exchanges. According to the ACR, the move could hinder patients with complex rheumatologic conditions from getting access to treatments that they need.

The ACR submitted comments in November 2017 regarding the agency’s proposed rule warning the CMS that allowing states to select their own EHB benchmark plans could cause states to seek cheaper, less comprehensive coverage that limits patient access to care, and particularly, access to biologic therapies.

In the comments, the ACR stated “In particular, with these policy changes we feel HHS may be singling out drug coverage, and an unintended consequence could be a state only allowing 1 drug per class to be covered, a decision that could affect treatment, efficacy, and choice.”

The ACR did applaud the CMS’s decision not to finalize the proposal for minimum essential coverage for Children’s Health Insurance Program (CHIP) buy-in programs. According to the statement, the ACR cautioned against finalizing the proposal, as it would leave children with rheumatic disease without guaranteed coverage.

“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,” David Daikh, MD, PhD, president of ACR, said in the statement.

“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 treatment they need to manage their conditions will be covered.”


ACR Responds to HHS Benefit and Payment Parameters Final Rule [news release]. ACR’s website. Accessed April 19, 2018.

American College of Rheumatology. Re: [CMS-9930-P]-Comments on Notice of Benefit and Payment Parameters for 2019 Proposed Rule. ACR’s website. Accessed April 19, 2018.

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