Even as the date for arguments before the US Supreme Court appears on the (somewhat distant) horizon, HHS, insurance departments and health carriers are proceeding with activities to implement the health reform Act adopted in 2010. While the future of the Act and portions of it remains uncertain, delay is not an option, and requirements under the Act are still being developed.
A major element involves the question of Essential Health Benefits (EHBs) for non-grandfathered plans affecting individuals and small groups under PPACA beginning in 2014. In December, HHS issued a bulletin announcing that some of the control over these aspects of coverage under the Act would be granted to the states in an attempt to provide states, carriers and consumers the flexibility and choice that many have urged. Included in the required benefit categories involved are:
- 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
- Pediatric services, including oral and vision care
Health plans would be required to offer coverage that is “substantially equal” to the benchmark plan chosen by the state and reflecting all 10 categories, but would have flexibility to make adjustments that retain the value of the coverage. The HHS plan announced in the bulletin permits states to choose their own benchmark for what constitutes an EHB package, and affects covered services. It does not address cost sharing (such as deductibles and copays) or calculations of actuarial value. According to HHS, for 2014 and 2015, states may choose from the following as a basis for their benchmark:
- One of the three largest small group plans in the state
- One of the three largest state employee health plans
- One of the three largest federal employee health plan options
- The largest HMO plan offered in the state’s commercial market
HHS plans to propose that the default benchmark for states opting not to select their own will be the small group plan with the largest enrollment in the state. Modifications could be made to a benefit category but must not reduce the value of coverage. For 2016 and beyond, HHS will assess the process “based on evaluation and feedback.”
The Department is encouraging public input on this subject by January 31, 2012, asking that comments be sent to EssentialHealthBenefits@cms.hhs.gov.
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