HHS Issues Final Rule on Essential Health Benefits

The Department of Health and Human Services (HHS) has released a 149-page final rule detailing the essential health benefits (EHB) requirements. Beginning in 2014, all new small group and individual market plans will be required to cover EHB categories. The rule largely codifies proposed rules that were released last November.

HHS Secretary Kathleen Sebelius praised the rule, stating, “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.”

Insurers must cover EHBs offered in 10 categories of care including emergency services, maternity, mental health, substance abuse, and prescription drugs. States are given substantial flexibility in selecting a benchmark plan, and many have been moving forward based on the proposed rule issued in November. Ian Spatz, a senior advisor for Manatt, Phelps and Philips, says the rule is good news for states as they continue to implement the Patient Protection and Affordable Care Act (PPACA). “Over the summer, we’ll get to see what the plans look like and especially how much they will cost,” Spatz said.

The rule also clarifies that insurers must have policies that permit patients to get “clinically appropriate” prescriptions, even if those drugs are not on the insurer’s list of covered medications. This will provide a great deal of relief to cancer patients that may have been hit with tens of thousands of dollars in prescription drug costs.

Stephan Finan, director of policy for the American Cancer Society’s Cancer Action Network, lauds this as an improvement. “It suggests that if you need a drug and that’s not on the formulary, you can get it, which was not the case before,” he said.

Under the new rule, insurers will not be able to charge a co-payment if a polyp is removed during a colonoscopy.  Until this new provision, insurers were able to reclassify the procedure as “diagnostic,” thus forcing liability back to the patient. The new rule also greatly expands mental health and substance abuse services.

While many are praising the final rule, the Children’s Hospital Association (CHA) expressed disappointment that HHS did not provide a strong definition of “habilitative” services for children. CHA released a statement expressing concern “that the flexibility HHS has given states to select services to include in essential health benefits packages could result in the exclusion of critical services for children, particularly those with severe disabilities and lead to state-by-state disparities.”

Although the final rule may, in fact, lead to disparities among states, the rule suggests HHS is taking a comprehensive approach to incorporating over 11,000 comments on previous EHB bulletins. According to HHS, comments were received by a wide variety of stakeholders including states, tribes, health plan issuers, consumer groups and health care providers. The final rule appears to be an effort to address many of these comments in a single, integrated platform.

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