HHS Takes Another Step Toward Defining Essential Health Benefits

The Department of Health and Human Services continues to parse out potential requirements for essential health benefits A proposed rule released Tuesday reveals that HHS wants to use the small group market plan and product with the largest enrollment as the default benchmark plan, but only if a state doesn’t select its own benchmark.

HHS also proposes that the National Committee for Quality Assurance and the non-profit URAC serve as the interim accrediting organizations for health plans seeking to be part of the state health insurance exchanges.

The Patient Protection and Affordable Care Act requires HHS to define the EHBs. These are 10 categories of service that must be offered beginning in 2014 by HIEs and individual and small group health insurance policies. The ACA charges HHS with making the final EHB call after getting input from the Department of Labor and the independent Institute of Medicine.

The proposed rule follows the December 2011 release by HHS of a 15-page bulletin that was more or less an EHB trial balloon. The proposed rule incorporates some of the 11,000 stakeholder comments received in response to that bulletin.

HHS intends to allow EHBs to be defined by a benchmark plan selected by each state. The benchmark will serve as a reference for the scope of services and limits to be offered. In the bulletin, HHS proposed four possibilities for benchmark plans if a state doesn’t select its own benchmark.

Now HHS intends to propose that the benchmark would be the small group market plan and product with the largest enrollment. To begin that process HHS proposes that data be collected from the three insurers with the largest plan and product enrollment in the small group market. The data would include information on enrollment, covered benefits, and treatment limitations of those coverage benefits, as well as a list of covered drugs and information regarding any prior authorization or step therapy required.

Data collected in 2012 would define EHBs for plan years 2014 and 2015. HHS plans to revisit this approach in 2016.

The proposed rule also presents a two-phase approach for recognizing the credentialing organizations for health plans that want to participate in HIEs. On an interim basis two familiar organizations, the NCQA and URAC, which are already responsible for most health plan accreditations, will handle those duties. In the short run their selection will keep accreditation on track to begin in early 2013.

In future rulemaking HHS intends to propose a recognition process that includes an application process, standards for recognition, a criteria-based review of applications, public participation, and public notice of the recognition.

HHS is soliciting comment on other data elements that might be helpful and wants input on whether closed block products or association products should be included as options in the selection of the largest three products.

Comments on the proposed rule will be accepted here through July 4.