Final Rule Defining Essential Health Benefits Released

The final rule defining the essential health benefits required to be provided by health insurance companies in order to be qualified under PPACA has been released by the HHS.
The U.S. Department of Health and Human Services has issued the final rule (the "Rule") setting forth the essential health benefits that health insurance companies will be required to provide in order to be qualified under the Patient Protection and Affordable Care Act ("PPACA"), as well as other standards required under the Obama administration's healthcare reform initiative. The Rule, which amends 45 CFR parts 147, 155 and 156, is available here.

The essential health benefits package includes ten (10) mandated categories of benefits.
Under the Rule, a health insurance company "offering health insurance coverage in the individual or small group market must ensure that such coverage includes the essential health benefits package." 45 CFR § 147.150(a). The "essential health benefits package" or "EHB package" includes at least ten (10) statutorily-defined categories of benefits; additionally, the benefits must be provided in accordance with the provisions of the Rule, limit cost sharing as required by the Rule, and provide distinct levels of coverage described under the Rule. 45 CFR § 156.20.

The ten (10) categories of benefits required under the EHB package include the following:
  1. Ambulatory patient services.
  2. Emergency services.
  3. Hospitalization.
  4. Maternity and newborn care.
  5. Mental health and substance use disorder services, including behavioral health treatment.
  6. Prescription drugs.
  7. Rehabilitative and habilitative services and devices.
  8. Laboratory services.
  9. Preventive and wellness services and chronic disease management.
  10. Pediatric services, including oral and vision care.
The prescription drug benefits of an EHB package, as well as the mental health, substance abuse and behavioral health treatment coverage, must meet specific requirements in order to be qualified under the Rule. Preventive health service coverage and habilitative service coverage also must meet certain requirements under the law as specified by the Rule. 45 CFR § 156.115(a).

The Rule prohibits "discrimination" based on age, medical dependency or other health conditions.
A health insurance company's health policy or plan does not qualify as providing essential health benefits "if its benefit design, or the implementation of its benefit design, discriminates based on an individual's age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions." 45 CFR § 156.125.

The Rule further specifies actuarial value requirements for specific levels of coverage under qualified health plans, as well as express rules regarding the calculation of such actuarial value.

A number of additional requirements, as well as additional provisions regarding the requirements previously described, are set forth in the Rule.

3 comments:

  1. In the list of essential services designated in ACA, where are contraceptive services?

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  2. I've looked at what I think is the relevant section of ACA and have found no reference to contraceptives as a required basic benefit. What is the legislative authority for it? Is it simply the latitude that ACA grants to the Secretary?

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    Replies
    1. Mike, thanks for the comment. The contraceptive coverage provisions arose as part of the regulations adopted by the U.S. Department of Health and Human Services (HHS) under the Patient Protection and Affordable Care Act (PPACA). The HHS rules generally require most health insurance plans to cover "preventive services for women including recommended contraceptive services without charging a co-pay, co-insurance or a deductible." I believe the interim rule was issued in mid-2010, and then amended in August of 2011. In January of 2012, HHS Secretary Sebelius described a "temporary enforcement safe harbor" for certain "non-exempted, non-grandfathered group health plans," but I believe that expired in January of this year. So, the legislative authority is basically, as you said, the latitude that PPACA grants to HHS.

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