Healthcare Update: New HHS Reporting Rule Will Help Define “Essential Health Benefits”; CMS Ends Marketing Outreach for High-Risk Pools


    On June 1, the U.S. Department of Health and Human Services (HHS) released a proposed rule that would require the three largest small-group health insurance issuers in each state to report detailed benefit information to HHS, as well as prescription drug coverage information and any limits on the benefits offered. The data reported will be used to define the “essential health benefits” (EHBs) that will need to be offered by all plans that participate in state insurance exchanges.

    The Patient Protection and Affordable Care Act (PPACA) requires the establishment of state exchanges that are supposed to begin operating in 2014. Participating insurance plans, known as “qualifying health plans,” will need to provide coverage of 10 designated categories of EHBs, including ambulatory care, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive care and chronic disease management, and pediatric services.

    HHS’s definition of EHBs will be based on the benefits offered by a “benchmark” insurance plan selected by each state. If a state does not select a benchmark plan, HHS will use the plan with the largest enrollment in the state’s small-group market as the default benchmark. The three largest plans today are considered the potential default benchmark plans for 2014.

    The proposed rule will be published in the Federal Register on June 5, and public comments will be accepted for 30 days.

    Click here for a complete copy of the Update.

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