The U.S. Department of Health and Human Services (HHS) published a final rule in the Federal Register on February 25 that sets forth standards for health insurance issues related to coverage of essential health benefits (EHB) and actuarial value. In addition, the final rule establishes a timeline for when qualified health plans (QHPs) should be accredited in federally facilitated exchanges. These regulations are slated to take effect April 26, 2013.
Starting January 1, 2014, under the Patient Protection and Affordable Care Act (PPACA), non-grandfathered insurance plans in the individual and small group market and those in health insurance exchanges will be required to provide coverage of benefits or services in ten separate categories that reflect the scope of benefits covered by a typical employer plan. A QHP is one that provides a benefits package that covers EHB, includes cost-sharing limits, and meets minimum value requirements.
With respect to the scope of EHB, each state will be permitted to identify a single EHB-benchmark plan-defined as the standardized set of EHBs that must be met by a QHP-from the following four choices:
- Small group market health plan, defined as the largest health plan by enrollment in any of the three largest small group insurance products by enrollment in the state’s small group market;
- State employee health benefit plan, which is any of the largest three employee health benefit plan options by enrollment offered and generally available to state employees;
- Any of the largest three national federal employees health benefits program (FEHBP) plan options by aggregate enrollment that is offered to all health benefits eligible federal employees; or
- The coverage plan with the largest insured commercial non-Medicaid enrollment offered by a health maintenance organization (HMO) operating in the state.
If a state does not make a selection, the default base-benchmark plan will be the first option discussed above. A benchmark plan that does not provide the requisite coverage in each of the ten categories must be supplemented using the process outlined in the rule. The ten specific categories 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
The PPACA created four tiers of health plans available for purchase through the exchanges to help participants and potential enrollees compare various health plans. Each tier is defined by its actuarial value (AV), called “metal levels,” which is the percentage of the total allowed costs of benefits that is paid by the health plan. A bronze plan has an AV of 60 percent; a silver plan has an AV of 70 percent; a gold plan has an AV of 80 percent; and a platinum plan has as an AV of 90 percent. The value may vary by plus or minus 2 percent.
For more information about EHBs and coverage of orthotics and prosthetics, read “HHS Moves Forward with Development of Essential Health Benefits Package,” by Peter W. Thomas, JD, and Theresa Morgan, in the March 2012 issue of The O&P EDGE.
