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:
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.