The Department of Health and
Human Services ("HHS") has issued final regulations that:
(i) address the collection of data from certain insurers to define
essential health benefits ("EHBs"); and, (ii) establish a
process for recognizing accrediting entities to certify qualified
health plans for health insurance exchanges (the
"Exchanges") under the Patient Protection and Affordable
Care Act ("PPACA").
PPACA requires HHS to define
EHBs, which are 10 general categories of service that must be offered
beginning in 2014 by non-grandfathered health plans, including
qualified health plans ("QHPs") offered through Exchanges.
The EHB categories are:
and newborn care,
health and substance use disorder services,
and habilitative services and devices,
and wellness services and chronic disease management, and
In 2011, HHS announced that
it would leave the task of defining EHBs up to the individual states.
However, HHS reserved the right to establish a process that states
must follow in defining EHBs. According to the final
regulations, HHS will publish the state-specific benchmarks and make
final approval of the EHBs.
Specifically, the final
regulations address the states' collection of data from potential
benchmark plans so they may define EHBs. According to the final
regulations, EHBs are to be defined by a benchmark plan selected by
each state. The final regulations specify that for 2014 and 2015,
data from insurers that offer the three largest small group products,
by enrollment, must be used to identify the benchmark plan for each
In addition, the final
regulations establish the first phase of a two-phased process for
recognizing accrediting entities to certify QHPs for the Exchanges.
In phase one, the National Committee for Quality Assurance
("NCQA") and URAC (formerly the Utilization Review Accreditation
Commission) are identified as interim accrediting agencies. Both of
these entities have already satisfied the accreditation requirements
specified in the regulations. In phase two, a criteria-based review
process will be adopted through future rulemaking.
Ultimately, HHS will issue
comprehensive regulations that define a state's essential benefits
under the ten categories listed in PPACA. The definition of EHBs is
significant not only for plans and policies offered in the small and
individual group markets, but also for the prohibitions and
restrictions on lifetime annual dollar limits, which apply directly
to the value of EHBs.