Final Essential Health Benefits Rule Unveiled

By Joe Touschner

It’s been a long process involving an in-depth study, state choices, and stakeholder comment on multiple rounds of proposals from HHS, but we now have the final essential health benefits rule.  Along with it came final rules on actuarial value for QHPs and cost-sharing limits in many types of private health coverage.

For those who have followed the process, there is not a lot that’s new in the final rule—it largely adopts the regulations that HHS proposed last November.  But a few items are worth noting.  First, HHS officials mentioned that more than one state changed its benchmark plan selection through comments on the proposed rule.  So you may want to check CCIIO’s list of state benchmarks  to confirm the benefits for your state.

The final rule also clarifies that states may limit benefit substitution by insurers.  Washington state has decided to do so for the first year of exchange coverage and other states may want to consider a similar move.  While the rule does not change the requirement that insurers cover as many drugs per class as the benchmark plan (with at least one in each class), it does promise future guidance on a way for patients to access drugs they need that are not on their insurers’ formularies.

Finally, HHS addressed pediatric dental benefits for EHB covered plans OUTSIDE the marketplaces (exchanges).  The law allows plans IN a marketplace to omit pediatric dental benefits if those benefits are offered by a stand alone plan.  But it was unclear if plans OUTSIDE the marketplace would still be required to offer pediatric dental services.  The final rule says that plans outside the marketplace will be considered to offer the EHBs even if they don’t offer pediatric dental benefits themselves, but are “reasonably assured” that their enrollees have pediatric dental coverage through a stand alone plan in the marketplace.  HHS officials suggested that plans could be reasonably assured of the existence of dental coverage for kids through documentation from the marketplace or contact with the dental plan itself.

Unchanged in the final rule are the provisions we’ve been tracking on habilitative services and cost-sharing in stand alone dental plans for kids.  As proposed, states can either define habilitation benefits or leave it to insurers to do so.  And despite our strong suggestion to apply one limit, the rule says stand alone dental plans can have an out-of-pocket spending limit separate from the plan that provides the remainder of the EHBs.  So families with high needs could face out-of-pockets costs above the limits established in the ACA.

With this final rule, insurers will have a more clear sense of the benefits they are required to offer in the individual and small group markets next year.  As the plans are defined, we’ll have one more piece of the 2014 coverage puzzle in place.