Essential Health Benefit Regs Invite Comment, Provide New Info on Habilitative Services and Cost-Sharing

By Joe Touschner

As we noted just before Thanksgiving, HHS recently proposed regulations on essential health benefits (as well as cost-sharing and actuarial value).  A few new developments are noted below, but the most important aspect of the rule is its opportunity for comment.  Included with the rule is a proposed set of essential health benefits for every state.  Many states submitted a choice for their benchmark plan, others were assigned the largest small group plan as a default.  Any stakeholders that want to weigh in on whether these plans represent a good choice for their states have until December 26 to submit comments to HHS.  So time is of the essence!

You can find the benefits proposed for your state at this page on the CCIIO website.   Also be sure to check out CCIIO’s Guide to Reviewing Proposed State EHB Benchmark Plans.

What else is in the proposed rule?  One thing that’s NOT included is further  definition of the ten categories of services that must be part of the Essential Health Benfits.  We had hoped for more clarity on what services would make up each category, especially the pediatric services category.  HHS did provide more authority for states to define part of one of the categories—habilitative services.  A state can establish a definition for this category only if its benchmark plan lacks coverage for habilitation.  If it is lacking that type of benefit, the state may draw up its own definition to apply across the individual and small group market.  Alternatively, the state can leave it to insurers to define the category themselves.  The proposed rule also clarifies that states can limit or prohibit insurers’ ability to make substitutions within the EHB categories.

There were a number of provisions important for kids and families in the cost-sharing section of the rule, too.  Like EHBs, these cost-sharing regulations apply in the individual and small group markets starting in 2014.  The proposal notes that for family plans, the cost-sharing limits will be double the limits for single coverage.  This works well for larger families, since cost-sharing limits will be no higher for families of 3, 4, or 5 or more people than they are for families of 2.  More concerning is that the proposed rule allows a separate cost-sharing limit for stand-alone pediatric dental plans.  This means that families who reach the cost-sharing limit for medical benefits may still need to pay out-of-pocket for dental co-pays and co-insurance if they use a stand alone plan.

You can find the full text of the rules here.  Remember that, like the holiday season, the comment deadline of December 26 will be here before you know it.