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HHS Issues 2014 Rules for Health Plans, Exchanges

Cheryl Clark, for HealthLeaders Media, November 21, 2012

The health plan organization also pledged to appeal to Congress to push back the ACA's $100 billion tax on health insurance "that will further add to the cost of coverage for families, small businesses, Medicare Advantage beneficiaries, and Medicaid managed care plans."

The American Hospital Association was not prepared to give a response to the rules yesterday. But Dan Mendelson, CEO of the Washington, D.C.–based health advisory company Avalere Health, says hospitals should appreciate the new proposed rules because CMS "is trying to create coverage that looks more like the commercial marketplace, and is proceeding more aggressively to make sure these exchanges are ready. A lot of folks in the hospital community might have doubted that, and these rules today show them that they're moving along."

Some consumer groups said the rules don't go far enough to guarantee health plan enrollees access to all the drugs they might need.

"By leaving the decision up to the states of which drugs insurance plans must cover, we fear many patients, particularly those with complex medical conditions, may not have the coverage they need,” said Carl Schmid, executive director of the AIDS Institute.

Here, in a nutshell, is what the three rules would require.

1. Essential health benefits
The administration retained 10 basic categories that each plan in the exchanges must offer, including ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitation services, lab services, preventive and wellness services and chronic disease management, and pediatric services including oral and vision care.

Qualifying exchanges should provide benefits that are equivalent to a "typical employer plan" or benchmark plan, in each state, for which there are four options:

  • The largest plan by enrollment in the state's small group market
  • Any of the largest three state employee health benefit plan options by enrollment
  • Any of the largest three national Federal Employees Health Benefits Program plan options
  • The largest insured commercial HMO in the state.
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1 comments on "HHS Issues 2014 Rules for Health Plans, Exchanges"


Elizabeth Beil (11/29/2012 at 4:17 PM)
If we won't have the exchanges up and running until 10/01/2013 I assume that we will not know the companies/plans that are participating. I do the credentialing for our practice and wonder how will these as yet to be determined companies are going to be able to credential the providers to service these plans. As it is it takes the insurance companies many months to complete credentialling or even recredentialing our practitioners.