HealthLawProf Blog

Editor: Katharine Van Tassel
Concordia University School of Law

Wednesday, December 5, 2012

ACA NPRM: Essential Benefits


HHS published the NPRM concerning essential health benefits (EHBs) for qualified insurance plans on November 26, 2012. Comments must be submitted within 30 days of November 26--that is, on December 26, 2012.  HHS has already received about 11,000 comments in response to an earlier bulletin about its planned approach to defining EHBs.

Several important features of the proposed rule might be particularly noteworthy for blog readers.

    --State-mandated benefits enacted before December 31, 2011, will count as part of the EHB for that state--so states will not have to pick up additional costs associated with these benefits.

    --States may select a "base-benchmark" plan from among the following options, a design chosen to enable ease of transmission from current market conditions but with the risks of allowing continuing gaps in coverage and considerable variation among states:

        --The largest plan by enrollment in any of the three largest small group insurance products in the state's small group market

        --any of the three state employee plans with the largest enrollment

        --any of the three national federal employee plans with the largest enrollment

        --the commercial non-Medicaid HMO with the largest enrollment in the state 

    --States are encouraged (but not required) to seek public input before selecting a benchmark plan, and to have a selection process that is open and transparent.

    --There are provisions for supplementing base benchmark plans that do not include coverage for any one or more of the 10 categories of benefits required by ACA; an example is pediatric vision services.  There are also some uniform definitions of categories; for example, pediatric care includes all care up to age 19. Mental health and substance abuse treatment benefits must be provided at parity as required under the 2008 Mental Health Parity and Addiction Equity Act.

    Plans may provide a variety of pharmacy benefits.  However, plans must cover at least the greater of one drug in every category and class, or the number of drugs in each category and class as the EHB benchmark plan.

    --Appendix A to the NPRM lists benchmarks selected by states to date, and indicates what a default benchmark would look like for states that have not selected a benchmark plan. The default will be the largest plan by enrollment in the largest product in the state's small group market. States have until the closing of the comment period (Dec. 26, 2012) to make or change their benchmark selection.


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