In a recent comment letter, the Pain Care Coalition, which includes the American Society of Anesthesiologists, American Academy of Pain Medicine, American Headache Society, and American Pain Society, urged CMS to include the assessment, diagnosis, treatment and management of a patient’s acute or chronic pain in the essential health benefits (EHB) package under the Patient Protection and Affordable Care Act (PPACA). 

PPACA directs the Secretary of Health and Human Services to define EHB, and in December 2011, CMS released the Essential Health Benefits Bulletin (Bulletin) which details the agency’s intended regulatory approach.  According to the Bulletin, CMS intends to propose that each state pick a benchmark plan among those plans currently offered in the state, and the benefits and services included in the benchmark plan would be the EHB package.  EHB must include coverage of ten mandated benefit categories identified in PPACA (ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness screenings and chronic disease management, and pediatric services).  The benchmark plan will serve as a reference plan, and health insurance issuers in the states must offer benefits “substantially equal” to the benefit package offered by the benchmark plan.  Beginning in 2014, non-grandfathered plans in the individual and small group markets both inside and outside of the Exchanges must cover EHB. 

In the comment letter, the Pain Care Coalition explains that pain care fits poorly in CMS’s strictly categorical approach to benefit design.   While pain care may be viewed as falling within one or more of PPACA’s ten mandated coverage categories, CMS’s intended approach does not reflect that pain care is often complex and crosses multiple care settings.  For that reason, the Pain Care Coalition urged CMS to “adopt a minimum standard for health insurance coverage that speaks to comprehensive pain care across other benefit categories.”  In short, “one element of an EHB package should be the adequate assessment, diagnosis, treatment and management of a patient’s acute or chronic pain.”

The Pain Care Coalition’s comment letter on the EHB package is available here, and the Bulletin is available here. 

Click here for additional information on ASA’s advocacy activities related to pain medicine.