HHS Takes Another Step Toward Defining Essential Health Benefits

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.