Latest update on Essential Benefits data collection
In July 2012, the Department of Health and Human Services (HHS) released the final rule on data collection standards that will help define the Essential Benefits offered through qualified health plans in individual and small group markets offered within the Health Insurance
Exchanges or outside of them.
A bit of background
The Essential Health Benefits, as defined in Section 1302(b) of the Patient Protection and Affordable Care Act, call broadly for benefits plans to offer at least the following categories:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance disorder services, including behavioral health treatment
- Prescription drug coverage
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive, wellness and chronic disease management
- Pediatric services, including oral and vision care
One thing that’s already been determined is that some care, such as women’s health services must be provided without copayment. These services include:
- Mammograms
- Blood pressure test
- Breast feeding counseling and equipment
The data collected will help define the parameters for services and treatments. For example, it will help determine whether physical therapy benefits are offered with a treatment limitation, such as a limit to 10 physical therapy visits per year. Other examples include the drugs typically covered by the benchmark plans.
The goal is to provide predictability for consumers who purchase coverage in these markets. The benchmarks make it easier to compare coverage across health plans, and ensure that individual and small group subscribers have the same access to the same scope of benefits provided under a typical employer plan.
What the update means
HHS is allowing states some flexibility in determining how they will implement the Essential health Benefits. The latest update calls for a benchmark approach to accomplish this. This approach is intended to make sure the required benefits will most closely reflect the needs of the individuals in that state.
In its earlier draft, the government proposed a choice of four different possible plan types to use as a benchmark model:
- One of the three largest small group plans in the state by enrollment
- One of the three largest state employee health plans by enrollment
- One of the three largest federal employee health plan options by enrollment
- The largest HMO plan offered in the state’s commercial market by enrollment
In the July 20 update, the government only addresses “One of the three largest small group plans in the state by enrollment” as a benchmark. This update is part one of a two-phased approach to implement these standards set under the Affordable Care Act. As the information continues to evolve, Unum will keep you up to date on any further clarification on the other three potential benchmarks.
For more information on the data collection:
- See the HHS data collection update
- Read the HHS listing of the largest three small group products by state, providing details on plan options to help states in their benchmark selection.
Employers: Employers will need to stay up-to-date on these criteria if their plans are subject to the Essential Health Benefits requirement.
Brokers: As employers look to them for advice on formulating a benefits strategy for health care reform, it will be important that brokers stay up to date on the Essential Health Benefits and the way they may be implemented differently in various states.