The U.S. Department of Health and Human Services (HHS) has issued a final rule setting forth the health plan data that will be collected from certain insurance issuers as part of the agency’s process for determining what constitutes “essential health benefits” (EHB) under the Affordable Care Act. As previously discussed, starting January 1, 2014, non-grandfathered insured plans in the individual and small group market and those in the future insurance exchanges will be required to provide coverage of benefits or services in 10 separate categories that reflect the scope of benefits covered by a typical employer plan. Last December the agency issued an Essential Health Benefits Bulletin that described the HHS’s regulatory approach for determining which benefits will be deemed essential. This guidance explained that EHB would be defined by one of four benchmark plans selected by each state, including the largest plan by enrollment in any of the three largest small group insurance products in the state’s small group market.

To this end, the final rule “establishes that issuers of the largest three small group market products in each state report information on covered benefits” in order for the HHS to better define the EHB’s scope, and outlines the first of two phases that will be used to recognize accrediting entities for purposes of certification of qualified health plans (QHPs). The rule states that in the first phase, the National Committee for Quality Assurance (NCQA) and URAC will be recognized as the accrediting entities on an interim basis. For phase two, the HHS will adopt via rulemaking a criteria-based review process.

According to the HHS, the final rule “incorporates the provisions of the proposed rule with some substantive modifications, along with additional non-substantive changes to improve clarity.” The more substantive changes include the following:

  • The definition of treatment limitations is modified to include only quantitative limits.
  • The rule establishes a submission deadline of September 4, 2012 for applicable issuers. The rule directs issuers to use the Health Insurance Oversight system to make these submissions.
  • The rule eliminates the inclusion of essential community providers under the network adequacy standards for accreditation.
  • The final rule stipulates that network adequacy standards for accreditation be, at a minimum, consistent with general requirements for network adequacy for QHP issuers outlined in other sections of the rule.
  • The final rule establishes that an accrediting entity must provide current accreditation standards and requirements, processes, and measure specifications for performance measures to the HHS within 60 days of the rule’s July 20, 2012 publication in the Federal Register. According to the HHS, “60 days is a reasonable time for accrediting entities to submit their current accreditation processes, standards, and requirements.” The HHS also finalized the timeline for these entities to submit any proposed changes or updates to the accreditation and measurement process. Such changes must be submitted to the HHS 60 days prior to public notice.
  • The rule includes an exception to protect personally identifiable information.

Finally, the agency noted also that it intends to publish state-specific benchmarks for notice and comment.