Final Rule Issued on Essential Health Benefits under Health Care Reform

On February 20, the Department of Health and Human Services (HHS) issued a final rule on essential health benefits and actuarial value. Beginning January 1, 2014, non-grandfathered insurance plans in the individual and small group markets and in the exchanges must provide coverage for essential health benefits.

Essential health benefits include 10 categories of care: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. Plans must also cover a minimum of 60 percent of the actuarial value of covered medical services.

States may designate health plans operating in their states as benchmarks for essential health benefits.  If states do not make a designation, HHS will choose the largest small group plan operating in that state. Currently, 27 states and the District of Columbia have chosen their benchmark plans.

The rule also sets standards for how qualified health plans offered in the exchanges will be accredited. Watch for more on this new final rule in upcoming MSEC publications.