On December 16, 2011, HHS (Department of Health and Human Services) released a “bulletin” outlining a framework for states to select “essential health benefits” benchmarks in implementing state health insurance exchanges under the Affordable Care Act (ACA). A notice of proposed regulations is being developed. Public comments are sought.
States will define Essential Health Benefits by identifying a specific benchmark plan, which will serve as a reference plan for Qualified Health Plans (QHPs) that offer policies within insurance exchanges. This benchmark or reference plan will reflect the scope of services and service limitations offered by a “typical employer plan” within the state.
Under the Affordable Care Act, individuals who are newly eligible for insurance coverage will be enrolled in benchmark plans. These plans must cover at least the essential health benefits package, which includes ten specified categories listed in the ACA:
- 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
States can benchmark their plan to one of the below plans or develop their own as long as it is actuarially equivalent to one of the options. States can pick from:
- One of the three largest small group insurance plans in the state;
- One of the three largest State employee health benefit plans by enrollment;
- One of the three largest national Federal Employee Health Benefit Plan (FEHBP) plan options by enrollment; or
- The largest commercial non-Medicaid Health Maintenance Organization (HMO) plan operating in the State.
HHS is considering two approaches to habilitative services: (1) Plans would need to offer habilitative services at parity with rehabilitative services, or (2) Plans would identify which habilitative services they will cover, and submitting this coverage plan to HHS. This option would be a transition approach, with HHS further defining habilitative services in the future.
Mental health (MH) and substance use disorder (SUD) services must be included in the benefits packages for individual and small business insurance plans and the Medicaid expansion population. The December 16 HHS announcement expands the Mental Health Parity and Addiction Equity Act’s (MHPAEA) requirements to the individual and small group markets inside and outside of the new insurance exchanges as well as to the Medicaid expansion population. (As passed in 2008, MHPAEA exempted individual and small employer plans from the law’s requirements.)
HHS is seeking public comments on their December 16 “bulletin” by January 31. HHS will be issuing proposed rules, to provide regulatory guidance. During January, AAHD will be developing comments on the HHS guidance as members of the following national coalitions:
- Consortium for Citizens with Disabilities
- Coalition for Whole Health
- Disability Rehabilitation and Research Coalition
- Habilitation Benefits Coalition
- Mental Health Liaison Group
- National Health Council
On January 25, HHS posted a new analysis – “Essential Health Benefits: Illustrative List of the Largest Three Small Group Products by State.” Download the analysis PDF.
For further information, contact AAHD Policy Associate Clarke Ross.
Available for download are:
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