HHS Publishes Final Rule Regarding Essential Health Benefits and Actuarial Values Applicable to Certain Individual, Small Group and Medicaid Plans


Beginning in 2014, all non-grandfathered health insurance coverage in the individual and small group markets, Medicaid benchmark and benchmark-equivalent plans, and Basic Health Programs (if applicable) must cover essential health benefits (EHB), which include items and services in 10 statutory benefit categories, such as hospitalization, prescription drugs, and maternity and newborn care, and are equal in scope to a typical employer health plan.  In addition to offering EHB, non-grandfathered health insurance plans must meet specific actuarial values (AVs):  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.  These AVs, called “metal levels,” should assist consumers in comparing and selecting health plans by allowing a potential enrollee to compare the relative payment generosity of available plans.  Taken together, EHB and AV are intended to increase consumers’ ability to compare and make an informed choice about health plans. 

HHS has provided information on EHB and AV standards in several phases.  Most recently, HHS issued a final rule last week that outlines Exchange and issuer standards related to coverage of EHB and AV.  The rule also finalizes a timeline for qualified health plans to be accredited in Federally-facilitated Exchanges and amends regulations providing an application process for the recognition of additional accrediting entities for purposes of certification of qualified health plans.

The final rule provides little in the way of guidance to insurance issuers regarding the nature of required health benefits and instead gives substantial authority to states to make those determinations.  Indeed, although HHS recognized that “[s]everal commenters recommended that HHS have a single, uniform federal [essential health benefits] package because they are concerned that the proposed benchmark options have a large degree of variation in covered benefits which may lead to inconsistent [essential health benefits] packages from state to state,” HHS declined to provide detailed guidance about the necessary contours of essential health benefits packages.  As HHS explained, “[t]he benchmark approach for defining EHB sought to balance the statutory ten benefit categories and affordability while providing states—the primary regulators of health insurance markets—with flexibility.”

HHS’s final rule is available by clicking here.

Reporter, Ramsey Prather, Atlanta, +1 404 472 4624, rprather@kslaw.com.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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