The U.S. Department of Health and Human Services (HHS) has issued a proposed rule (pdf) that sets forth the health plan data that will be collected from certain insurance issuers as part of the agency’s process for determining what constitutes “essential health benefits” (EHB) under the Affordable Care Act. Generally, as of January 1, 2014, non-grandfathered insured plans in the individual and small group market and those in the future insurance exchanges will be required to provide coverage of benefits or services in 10 separate categories – including emergency services, prescription drugs, and maternity and newborn care – that reflect the scope of benefits covered by a typical employer plan.

In December 2011, the HHS issued an essential health benefits bulletin that described its proposed regulatory approach in determining which benefits will be deemed essential. This guidance explained that the HHS will propose that EHB be defined by a benchmark plan selected by each state, which could be modified as needed so long as the value of coverage is not reduced. The bulletin proposed four separate plan types that could be used as a benchmark: (1) the largest plan by enrollment in any of the three largest small group insurance products in the state’s small group market; (2) any of the largest three state employee health benefit plans by enrollment; (3) any of the largest three national federal employee health benefit plan (FEHBP) options by enrollment; or (4) the largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the state. If the state opts not to use one of these four plan types as its benchmark, HHS intends to propose that the default benchmark plan per state “be the largest small group market product in the state’s small group market.” In February of this year, the HHS issued additional guidance discussing the approach the agency plans to take in defining EHB.

The new proposed rule “includes data reporting standards for health plans that represent potential state-specific EHB benchmarks,” i.e., standards that would apply to issuers of the largest three small group market products in each state. The stated purpose of the proposed rule is to “collect sufficient information on potential benchmark plans’ benefits to enable plans seeking to offer coverage in the individual or small group market in 2014 to know what benefits will be included in the EHB benchmark.” Among other information, the proposal would require the relevant insurance issuers to provide administrative data necessary to identify their health plans; data and descriptive information on certain health plans; data on any treatment limitations imposed on coverage; data on drug coverage; and plan enrollment data.

In addition, the proposal sets forth the first of a two-part approach for “recognizing accrediting entities to implement the standards established under the Affordable Care Act for qualified health plans (QHPs) to be accredited on the basis of local performance by an accrediting entity recognized by the Secretary on a timeline established by the Exchange.” As part of the first phase, the National Committee for Quality Assurance (NCQA) and URAC would be recognized as accrediting entities on an interim basis. Phase two – which will be created through future rulemaking – will establish a criteria-based review process.

Comments on this proposal must contain the file code CMS-9965-P and be received within 30 days of the proposal’s June 5 publication in the Federal Register. Comments may be submitted electronically through the federal eRulemaking portal, or sent by regular mail to: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-9965-P, P.O. Box 8010, Baltimore, MD. Alternatively, comments may be hand-delivered to the Washington, DC office: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201.

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