HHS Releases Essential Benefits Guidance

by Rebecca Farley on November 21, 2012

The Department of Health and Human Services (HHS) this week released new guidance about the essential health benefits that will be available to consumers through individual, small group, and exchange-based insurance products beginning in 2014.

The proposed rule, scheduled to be published November 26 in the Federal Register, adheres closely to the Informational Bulletin published last December, which offered preliminary guidance about HHS’ intended approach. Public comments on the proposed rule will be accepted for 30 days after the November 26 publication.

Several key elements of the proposed rule will have a positive impact on people with mental health and addiction disorders:

  • The proposed rule includes language to assure non-discrimination in plan design, a major issue for people with chronic conditions. The rule prohibits cost-sharing structures, utilization management techniques, and benefit designs that discriminate against beneficiaries based on race, age, disability status, health status, quality of life, having high health care needs, or other characteristics. States must monitor and identify discriminatory benefit designs.
  • The Mental Health Parity and Addictions Equity Act applies to essential benefits. Plans that do not already include mental health and addiction benefits – or include these benefits but not at parity with medical/surgical benefits – must supplement their plans to come into compliance with parity. HHS did not offer specific guidance on the process by which plans should augment behavioral health benefits.
  • The definition of essential benefits includes both the required preventive services outlined in the ACA as well as any state-mandated benefits (for example, autism coverage mandates) that were in effect prior to December 31, 2011.
  • Deductibles will be limited to $2,000 for self-only coverage and $4,000 for individual coverage. These numbers will rise over time, indexed to the growth in average health insurance premium costs. Additional restrictions on total annual out-of-pocket spending also apply.

Other major provisions of the rule include:

Supplementing Essential Benefits: Many healthcare advocates have expressed concern that the benchmark plans states have selected to use as the basis for essential benefits (known as the “base-benchmark plan”) do not include adequate coverage of certain types of services. Most commonly, these base-benchmark plans do not cover pediatric dental and vision; however, two states’ selected plans do not cover mental health or substance use disorder benefits and 19 states’ plans do not cover habilitative services. The proposed rule outlines a process by which states must supplement the base-benchmark plan if it fails to include a required category of essential benefits. For most benefits, this process is to draw that entire category of benefits from one of the other benchmark plan options. However, the process differs slightly for habilitative benefits. Here, HHS outlined a “transitional policy” designed to give states flexibility over their benefits packages. If the base-benchmark plan does not already include habilitative benefits, the state may create its own definition of required habilitative services. Should the state fail to do this, insurance plans may define and adopt their own set of habilitative services.

Benefit Substitutions: Consumer advocates have also been wary of plans’ ability to substitute different benefits for those found in the base-benchmark plan. The proposed rule clarifies that plans are permitted to implement substitutions within – but not across – benefit categories. Any substitutions must be actuarially equivalent to the original benefits, and substitutions cannot result in a plan design that discriminates against particular groups of people. Plans are also permitted to substitute coverage limitations (for example, restrictions on the amount, duration, or scope of services) but these must be “substantially equal” to the original benchmark plan limitations and cannot discriminate against particular groups of people.

Drug Coverage: In response to comments that its original intended approach to drug coverage could result in inadequate access to critical medications, HHS has slightly modified its “one drug per class” proposal. The new rule states that plans must cover the greater of: one drug in every category and class of the U.S. Pharmacopoeia; or the same number of drugs in every category and class that were covered in the base-benchmark plan. In practice, this means that most plans will likely have to cover more drugs than had been anticipated under the December 2011 bulletin. However, the National Council had strongly encouraged HHS to adopt the Medicare Part D pharmacy coverage rules, which include even stronger protections for psychiatric medications. We will continue to urge HHS to ensure that all consumers have access to the most appropriate psychiatric medication at the right time.

The National Council is analyzing and evaluating the potential impact of the proposed rule on consumers with mental health and addiction disorders and the providers who serve them. We be submitting comments to HHS and will make our comments available for others to use a template in submitting their own comments.


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