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The Wagner Law Group Description 

The Wagner Law Group, A Professional Corporation, is a nationally recognized ERISA & employee benefits, estate planning, employment, labor & human resources practice. 


Established in 1996, The Wagner Law Group has 19 attorneys engaged exclusively in employee benefits, estate planning and employment law. Five of our attorneys are AV rated by Martindale-Hubbell as having very high to preeminent legal abilities and ethical standards. The firm is among the largest ERISA boutiques in the country. Our practice is national in scope, with clients in more than 40 states and several foreign countries.






Contact Info

The Wagner Law Group


Massachusetts Office 

Tel: (617) 357-5200 

Fax: (617) 357-5250 

99 Summer Street 

13th Floor

Boston, MA 02110

Florida Office 

Tel: (561) 293-3590
Fax: (561) 293-3591
7121 Fairway Drive
Suite 203
Palm Beach Gardens, FL 33418


New York Office

Tel: (716) 650-5987

Fax: (716) 633-0301

333 International Drive

Suite B-4

Williamsville, NY 14221


San Francisco Office

Tel: (415) 625-0002

Fax: (415) 829-4385

315 Montgomery Street

Suite 902

San Francisco, CA 94104




August 2, 2012 

 State and Federal Law Alert







HHS Issues Final Rule on Defining Essential Health Benefits




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:

  • ambulatory patient services,
  • emergency services,
  • hospitalization,
  • maternity and newborn care,
  • mental health and substance use disorder services,
  • prescription drugs,
  • rehabilitative and habilitative services and devices,
  • lab services,
  • preventive and wellness services and chronic disease management, and
  • pediatric services. 

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 state.


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.





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This Newsletter is provided for information purposes by The Wagner Law Group to clients and others who may be interested in the subject matter, and may not be relied upon as specific legal advice.  This material is not to be construed as legal advice or legal opinions on specific facts. Under the Rules of the Supreme Judicial Court of Massachusetts, this material may be considered advertising.