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Final Rules for "Essential" Health Benefits

Feb 22, 2013

Final rules for “essential” health benefits were announced by the Department of Health and Human Services (HHS). The rule outlines health insurance issuer standards for a core package of benefits, called essential health benefits, that health insurance issuers must cover both inside and outside the Health Insurance Marketplace. Through its standards for essential health benefits, the final rule also expands coverage of mental health and substance use disorder services, including behavioral health treatment, for millions of Americans.

The rule gives states the flexibility to define essential health benefits in a way that would best meet the needs of their residents, this rule also finalizes a benchmark-based approach. This approach allows states to select a benchmark plan from options offered in the market, which are equal in scope to a typical employer plan. Twenty-six states selected a benchmark plan for their state, and the largest small business plan in each state will be the benchmark for the rest.

Essential Health Benefits
The Affordable Care Act ensures Americans have access to quality, affordable health insurance. To achieve this goal, the law ensures that health plans offered in the individual and small group markets, both inside and outside of Health Insurance Marketplaces, offer a core package of items and services, known as “essential health benefits.” Under the statute, EHB must include items and services within at least the following 10 categories:

  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 Affordable Care Act helps people get the health insurance they need,” said HHS Secretary Kathleen Sebelius. “People all across the country will soon find it easier to compare and enroll in health plans with better coverage, greater quality and new benefits.”

A new report by HHS, also released today, details how these provisions will expand mental health and substance use disorder benefits and federal parity protections for 62 million more Americans.In the past, nearly 20 percent of individuals purchasing insurance didn’t have access to mental health services, and nearly one third had no coverage for substance use disorder services. The rule seeks to fix that gap in coverage by expanding coverage of these benefits in three distinct ways:

  1. By including mental health and substance use disorder benefits as Essential Health Benefits
  2. By applying federal parity protections to mental health and substance use disorder benefits in the individual and small group markets
  3. By providing more Americans with access to quality health care that includes coverage for mental health and substance use disorder services

The rule additionally outlines actuarial value levels in the individual and small group markets, which helps to distinguish health plans offering different levels of coverage. Beginning in 2014, plans that cover essential health benefits must cover a certain percentage of costs, known as actuarial value or “metal levels.” These levels are 60 percent for a bronze plan, 70 percent for a silver plan, 80 percent for a gold plan, and 90 percent for a platinum plan. Metal levels will allow consumers to compare insurance plans with similar levels of coverage and cost-sharing based on premiums, provider networks, and other factors.

In addition, the health care law limits the annual amount of cost sharing that individuals will pay across all health plans – preventing insured Americans from facing catastrophic costs associated with an illness or injury. Policies in today’s rule also provide more information on accreditation standards for qualified health plans (QHPs) that will be offered through the Health Insurance Marketplaces (also known as Exchanges), one-stop shops that will provide access to quality, affordable private health insurance choices.

Together, these provisions will help consumers compare and select health plans in the individual and small group markets based on what is important to them and their families. People can make these choices knowing these health plans will cover a core set of critical benefits and can more easily compare the level of coverage based on a uniform standard. Further, these provisions help expand choices and competition on the Marketplaces.

For more information on today’s rule, visit: http://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.html

To view the rule, visit: http://www.ofr.gov/inspection.aspx

Source: Health and Human Services, News Release – Feb 20, 2013

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