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    HHS Releases Essential Health Benefits Proposed Rule

    The Department of Health and Human Services (HHS) released several proposed rules today dealing with insurance reforms, including the proposed rule "Patient Protection and Affordable Care Act; Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation." The proposed rule provides guidance to states on the essential health benefits (EHBs) that must be offered in most nongrandfathered qualified health plans (QHPs) that are offered in each state's affordable Health Insurance Exchanges ("Exchanges") as directed under the Affordable Care Act (ACA). The Exchanges are expected to create competitive marketplaces making health insurance plans more affordable for individuals. EHB applicability to Medicaid will be defined in a separate regulation. The Exchanges must become operational by January 1, 2014. (See related articles titled "Proposed Rule Protects Patients From Discriminatory Policies" and "HHS Proposes Incentives for Nondiscriminatory Wellness Programs in Group Health Plan.")

    The proposed rule outlines Exchange and issuer standards related to coverage of EHBs and actuarial value. The proposed rule reiterates the 10 mandatory EHB categories of (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services, including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services (under age 19), including oral and vision care. States must create EHB benchmark plans from their default benchmark state health plans by adding any mandatory categories that are not in their default plans. These nongrandfathered health plans must offer balanced benefits not unduly weighted toward any one category. 

    The proposed rule includes that:

    • States would determine EHB-benchmark plans that would serve as  reference plans and would reflect both the scope of services and limits offered by a typical employer plans in that state. This would allow states to build on coverage that is already widely available, minimize market disruption, and provide consumers with familiar products. Additionally, it is intended to balance consumers’ needs for  comprehensiveness and affordability, as recommended by the Institute of Medicine in its report on EHBs;
    • The EHB-benchmark plan must not include benefit designs that discriminate on the basis of an individual's medical condition, or against specific populations as described in the statute;
    • A transitional policy for coverage of habilitative services be implemented that would provide states with the opportunity to define these services if not included in the base-benchmark plan; states could determine the services they choose to provide under the habilitative category;
    • Covered benefits must remain substantially equal to those covered by the EHB-benchmark plan;
    • Certain preventive services must be offered without cost-sharing;
    • Health benefit substitution could only occur within benefit categories, not between different benefit categories. States have the option to enforce a stricter standard on benefit substitution or prohibit it completely;
    • An issuer cannot provide an EHB benefit design that discriminates based on an individual’s age, expected length of life, or present or predicted disability, degree of medical dependency, quality of life, or other health conditions;
    • States may require that a [nongrandfathered] QHP cover additional benefits beyond the 10 EHB categories;
    • A (nongrandfathered) health insurance issuer that offers health insurance coverage in the individual or small group market—inside or outside of the Exchange—ensure that such coverage offers the EHB package; and
    • HHS' secretary review the plans after 2 years, then similar policy thereafter, to ensure that gaps in access to care are remediated or advances in the relevant evidence base are included.

    Finally, the Affordable Care Act describes the levels of coverage that of the EHB packages offered in the Exchanges: actuarial values of 60% for a bronze plan, 70% for a silver plan, 80% for a gold plan, and 90% for a platinum plan.

    APTA will be commenting on this proposed rule. Comments are due on or around December 20.

    APTA's Regulatory Affairs department will provide full summaries of the 3 proposed rules shortly.


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