HHS Issues Guidance on ‘Essential Health Benefits’ under ACA

On December 16, 2011, the Department of Health and Human Services (HHS) recently issued a guidance bulletin detailing its current thinking on the implementation of ‘essential health benefits’ (EHB) under the Affordable Care Act (ACA). Specifically, the bulletin addresses covered services under the ACA’s mandate that certain insurers provide EHB by 2014. The ACA defines EHB as:

  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, and
  10. pediatric services, including oral and vision care.

Based on several months of research, HHS has proposed that EHB “be defined by a benchmark plan selected by each State.” This benchmark plan would then act as a reference for other plans and would reflect “both the scope of services and any limits offered by a ‘typical employer plan’ in that State,” as mandated by the ACA. HHS has also proposed that the benchmark plan be one of 4 possible plans:

  1. the largest plan by enrollment in any of the three largest small group insurance products in the State’s small group market;
  2. any of the largest three State employee health benefit plans by enrollment;
  3. any of the largest three national FEHBP plan options by enrollment; or
  4. the largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the State.

HHS’ bulletin likewise addresses the concern that benchmark plans may not cover habilitative services, pediatric oral care and pediatric vision care; and therefore presents several proposals for defining covered EHB in those situations.

Comments on the bulletin must be submitted by January 31, 2012 to: EssentialHealthBenefits@cms.hhs.gov. Read the entire bulletin here.

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The opinions expressed on this blog are those of the author and are not to be construed as legal advice.

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