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Small Business Employee Benefits and HR Blog

HHS Releases Essential Health Benefits Final Rule

On February 20, 2013, the Department of Health and Human Services (HHS) released a final rule on essential health benefits. This rule is intended to make it easier for consumers to compare and make informed choices about health plans. 

What Do The Final Rules Outline?essential health benefits final rule

The rule included the following:

  1. It finalized standards for health insurance companies about essential health benefit (EHB) coverage and the determination of actuarial value (AV). 

  2. It established a timeline for accrediting qualified health plans (QHPs) in federally facilitated marketplaces. 

  3. It outlines an application process for accrediting entities that want to be recognized in order to certify QHPs. 

  4. It clarifies how to determine Minimum Value for an employer-sponsored group health plan.

Essential Health Benefits Rules

The Affordable Care Act requires that health plans offered in the individual and small group markets, both inside and outside of Health Insurance Marketplaces, offer a core package of items and services, known as "essential health benefits," which must include items and services within at least the following 10 categories:

  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

  10. Pediatric services, including oral and vision care

Essential Health Benefits Benchmark Plans

The Affordable Care Act also directs that essential health benefits be equal to benefits offered by a "typical employer plan." To meet this requirement in every state, the final rule defines EHB based on a state-specific benchmark plan. These benchmark plan options include:

  1. The largest plan by enrollment in any of the three largest products by enrollment in the state’s small group market;

  2. Any of the largest three state employee health benefit plans options by enrollment;

  3. Any of the largest three national Federal Employees Health Benefits Program (FEHBP) plan options by enrollment; or 

  4. The HMO plan with the largest insured commercial non-Medicaid enrollment in the state. 

Twenty-six states selected their own benchmark. The final rule also clarifies that in the remaining states that do not make a selection, HHS will select the largest plan by enrollment in the largest product by enrollment in the state’s small group market as the default base-benchmark plan. The selected benchmark plans are already finalized for 2014.

The final rule includes standards to protect consumers against discrimination and ensure that benchmark plans offer a full array of EHB benefits and services. For example, the final rule:

  • Prohibits discriminatory benefit designs;

  • Includes special standards and options for coverage of benefits not typically covered by individual and small group policies today, including habilitative services; and

  • Includes standards for prescription drug coverage to ensure that individuals have access to needed prescription medications.

Below are the state-by-state benchmark plans with required benefits as outlined by the CCIIO Website (retrieved 2/27/2013). 

Note: The below Essential health benefits (EHB)-benchmark plans are based on 2012 plan designs, and therefore do not necessarily reflect requirements effective for plan years beginning on or after January 1, 2014. Therefore, when designing plans that are substantially equal to the EHB-benchmark plan beginning January 1, 2014, insurance companies may need to design plan benefits, including coverage and limitations, to comply with these requirements and limitations (e.g. the annual limit requirements).

Click here for a guide to reviewing EHB Benchmark Plans

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District Of Columbia

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

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