Final Rule On Essential Health Benefits Issued

The Department of Health and Human Services (HHS) has issued a final rule that would establish data collection standards necessary to implement aspects of the Patient Protection and Affordable Care Act (ACA), which directs HHS to define essential health benefits (EHB). The final rule outlines the data on applicable plans to be collected from certain issuers to support the definition of EHB. Also, the final rule establishes a process to recognize accrediting entities to certify qualified health plans (QHP). The rule was published in the July 20 Federal Register.

The ACA directs that EHB reflect the scope of benefits covered by a typical employer plan and cover at least the following ten general categories of items and services: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.


The HHS issued a proposed rule on this issue in June. The final rule incorporates most of the provisions of the proposed rule, with a few substantive changes. For example, the final rule changes the definition of "treatment limitations" to include only quantitative limits and removes the requirement for insurers to provide data on nonquantitative limits.

This final rule includes data reporting standards for health plans that represent potential state-specific benchmark plans. Specifically, the final rule establishes that issuers of the largest three small group market products in each state report information on covered benefits. The final rule requires that the three largest insurers (determined by enrollment as of March 31, 2012) in each state provide the HHS with a report, by Sept. 14, 2012, with the following information:

1. Administrative data necessary to identify the health plan;
2. Data and descriptive information for each plan on the following items:
1. All health benefits in the plan;
2. Treatment limitations;
3. Drug coverage; and
4. Enrollment;

In addition, the final rule establishes the first phase of a two-phased approach for recognizing QHP-accrediting entities. These accrediting agencies will implement the ACA's QHP-accrediting standards on the basis of local performance. Each accrediting entity must be recognized by the HHS on a timeline established by the Exchange and includes some data sharing and performance requirements for the entities. In phase one, the National Committee for Quality Assurance (NCQA) and URAC are recognized as accrediting entities on an interim basis. In phase two, future rules will adopt a criteria-based review process, the HHS noted.

For more information, contact Adam Block at (410) 786-1698, for matters related to essential health benefits data collection; or Deborah Greene at (301) 492-4293, for matters related to accreditation of qualified health plans.