HHS DEFINITION OF ESSENTIAL HEALTH BENEFITS

HHS ISSUES BULLETIN ON DEFINITION OF ESSENTIAL HEALTH BENEFITS

 

Dec. 21, 2011

 

The Department of Health and Human Services (HHS) issued a bulletin outlining proposed policies that will give states flexibility to define the “essential health benefits” required by the Affordable Care Act1 (the Act). 

 

Instead of issuing proposed regulations, HHS chose to release the information in the form of a “pre-rule bulletin”. The announcement provides states with a framework for defining, on their own, the essential health benefits that will apply in each particular state. Implementing regulations based on this approach are expected in 2012.

 

BACKGROUND

The Act requires that beginning in 2014, health plans offered in the individual and small group markets, provide a comprehensive package of items and services known as “essential health benefits”. Large group health plans and self-insured health plans are not required by the Act to cover essential health benefits.

 

Essential health benefits must include items and services within at least the following ten categories:

  • 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

 

STATE-SPECIFIC DEFINITIONS BASED ON “BENCHMARK APPROACH”

HHS intends to propose that essential health benefits will be defined using a benchmark approach. Under the Department’s intended approach, states would have the flexibility to select a benchmark plan that reflects the scope of services offered by a “typical employer plan”.

 

States would choose one of the following benchmark health insurance plans:

  • One of the three largest small group plans in the state based on enrollment
  • One of the three largest state employee health plans based on enrollment
  • One of the three largest federal employee health plan options based on enrollment
  • The largest HMO plan offered in the state’s commercial market based on enrollment

 

If a state chooses not to select a benchmark, HHS plans to propose that the default benchmark will be the small group plan with the largest enrollment in the state. 

 

The benefits and services included in the benchmark health insurance plan selected by the state would be the essential health benefits package. Plans could modify coverage within a benefit category as long as they do not reduce the value of coverage.

 

SUMMARY

This announcement dramatically changes what many expected to be a more uniform, national approach to the definition of essential health benefits. By allowing states to define essential health benefits based on existing small group plans already offered in the state, there will be few cases where there is change to the structure of individual and small group plans offered through an Exchange beginning in 2014.









1 “Affordable Care Act” means The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA).


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