The Department of Health and Human Services has released a final rule outlining data collection requirements for each of the insurance plans that may be used as a potential basis for the establishment of essential health benefits in each state. Essential health benefits (EHB) are the minimum standard of coverage that insurance plans must meet. The Affordable Care Act directs that the EHB reflect the scope of benefits covered by a typical employer plan and cover at least the following 10 general categories of items and services, which includes mental health and substance use disorder services, including behavioral health treatment. However, the ACA granted wide latitude to HHS in determining exactly how it would define essential health benefits within these guidelines.
Previous guidance from HHS indicated that it would take a state-based approach, with each state being able to craft its own essential benefits package based on the scope of benefits covered by a typical small-group employer plan in that state. HHS later published a list of the eligible plans in each state whose benefit package can be used as the basis for determining EHB.
The new rule outlines the scope of data that will be collected about each of these plans to assist states in defining their essential benefits. The data to be collected include: all health benefits in the plan, treatment limitations, drug coverage, and enrollment.
Importantly, the definition of “treatment limitations” in the final rule does not include nonquantitative limitations such as prior authorization of services or step therapy requirements. Health insurers had argued that collection data on these requirements would be too burdensome, despite advocates’ assertion that this data is needed to ensure that consumers are not subjected to undue restrictions in accessing the benefits outlined under the ACA. The ACA explicitly applied the 2008 Mental Health Parity and Addictions Equity Act to plans sold in the state health insurance exchanges. The parity law bars plans from setting quantitative and nonquantitative limitations for mental health and addiction services that are more restrictive than medical/surgical limitations. Advocates have expressed concern that small-group plans typically have imposed more burdensome cost-sharing requirements and treatment limitations that restrict consumers’ access to mental health and addiction treatment services. Without data on the plans’ nonquantitative limitations, it will be difficult to know to what extent each potential benchmark plan is in compliance with the federal parity law.
Insurance plans will have until September 4 to submit the requested data; at that time, states will be able to move forward with analyzing the plans’ benefits packages and determining which plan should be used as the basis for essential benefits. The final rule is available here until July 20; at that time it will be published in the Federal Register.