Final Rule Issued for Essential Health Benefits
3/6/2013 – In February, the Department of Health and Human Services  (HHS) finalized a key ACA rule that defines the “essential health benefits” (EHBs) that must be provided by health insurers in 2014 to individuals and small-group businesses inside and outside health insurance exchanges, as well as in Medicaid.  The benefits do not apply to self-insured plans.
The final rule does not differ much from the original proposed rule. Â The rule defines what must be covered in health insurance exchange (HIE) plans, prohibits discrimination on age or pre-existing conditions, describes prescription drug benefits and determines levels of coverage.
This rule establishes a benchmark-mark approach for the health insurance exchanges that will begin in January 2014, and are meant to make the health plan categories comparable, though states may require more from insurers. All health plans offered through exchanges are required to offer a core package of items and services within the following listed 10 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 managment
- Pediatric services, including oral and vision care
Each state must also identify a single EHB-benchmark plan, defined as the standardized set of EHBs that must be met by a qualified health plan (QHP) from the following four options:
- Small group market health plan, defined as the largest health plan by enrollment in any of the three largest small group insurance products by enrollment in the state’s small group market;
- State employee health benefit plan, which is any of the largest three employee health benefit plan options by enrollment offered and generally available to state employees
- Any of the largest three national Federal Employees Health Benefits Program plan options by aggregate enrollment that is offered to all health benefits eligible federal employees; or
- The coverage plan with the largest insured commercial non-Medicaid enrollment offered by a health maintenance organization (HMO) operating in the state.
If a state does not make a selection, the default base-benchmark will be the first option mentioned above.
Health plans will fall into one of four tiers defined by the actuarial value (AV), or percent paid by a health plan of the percentage of the total allowed costs of benefits. This tiering should assist consumers in comparing available health plans.
- Bronze – 60%
- Silver – 70%
- Gold – 80%
- Platinum – 90%
- Limits on the maximum out-of-pocket costs a consumer would face each year would apply to all policies.  That amount would be $6,250 for a single policyholder and $12,500 for a family based on this year’s rate. The 2014 number is expected to be slightly higher.
- Insurers offer at least one drug per therapeutic category, or the same number as a state’s benchmark plan, whichever is greater. Many state benchmark plans require at least two drugs per class.
- Insurers must have procedures to allow patients to get “clinically appropriate” prescriptions not on the plan’s list of covered medications.
- Insurers cannot charge consumers a co-pay for a screening colonoscopy, even if a polyp is found and removed.
- Insurers and must offer mental health and substance abuse disorder coverage that is comparable to their general medical and surgical coverage.
- Employer contributions to health savings accounts, (HSAs) and amounts under integrated Health Reimbursement Arrangements, (HRAs) that may only be used for cost sharing must be known to the insurer when the plan is purchased.
- Future exchanges will be required to establish a uniform period within which a QHP issuer that is not a already accredited must become accredited.
Tags: ACA, Accountable Care Act, Healthcare Reform, Medical Billing
