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CMS Finalizes Rule Seeking Information Regarding Essential Health Benefits

Erin Hertzog

Lindsey Murtagh

Melissa Bianchi

19 July 2012
Changing little from its proposed rule, CMS released a final rule that (a) describes the data the agency will collect from certain insurers to help define essential health benefits (EHB) and (b) outlines its approach for accrediting entities as Qualified Health Plans (QHPs) that can be sold through a health insurance exchange.

Data to Help Define the EHB:  Starting in 2014, the EHB must be covered by all non-grandfathered health plans in the individual and small group market, Medicaid benchmark and benchmark-equivalent plans, and Basic Health Plans, where applicable.  In December 2011, CMS released a bulletin detailing the agency’s intention to allow states to define EHB using a benchmark plan selected by each state. CMS also released a set of Frequently Asked Questions regarding the approach outlined in the EHB bulletin in February 2012.  While much about the EHB still remains unclear, this final rule provides some additional information regarding the process for defining the EHB package.

Specifically, the final rule creates a data collection requirement to “support the definition of essential health benefits.” As such, the final rule would require the issuers of the three largest health insurance products in each state to submit the following data to the agency by September 4, 2012:

  • Administrative data necessary to identify the relevant health plan;
  • All health benefits in the plan;
  • Treatment limitations;
  • Drug coverage; and
  • Enrollment.

Accreditation of QHPs:  Also starting in 2014, health plan must be certified as QHPs in order to be offered through a health insurance exchange.  The final rule outlines a two-phase approach for accrediting entities as QHPs.  Recognizing the time constraints imposed by upcoming deadlines regarding the establishment of health insurance exchanges, the agency will use the National Committee for Quality Assurance and URAC to accredit QHPs during the first phase. For phase two, the agency plans to develop its own accreditation process through future rulemaking.

Erin Hertzog

Lindsey Murtagh

Melissa Bianchi

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