We previously posted on the difficulties that state by state essential health benefits determinations could present for self-funded health plan sponsors.
CMS recently issued some guidance that could help. The guidance provides that to determine which benefits are essential health benefits for purposes of complying with the annual and lifetime dollar limits on essential health benefits, the Departments of Labor, Treasury and HHS will allow self-funded group health plans, and large group market health plans to choose ONE benchmark that is authorized by the Secretary of HHS (including any available benchmark option, supplemented as needed to ensure coverage of all ten statutory categories). Further, the guidance states that the agencies will use their enforcement discretion and work with those plans that make a good faith effort to apply an authorized definition of essential health benefits to ensure there are no annual or lifetime dollar limits on essential health benefits. While this means that large group health plans will still need to analyze the available benchmarks and pick one that works for their plans, it will probably soon become evident in the marketplace which benchmark is preferred. This approach is a welcome simplification for large group health plans.