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HHS Final Rule Addresses Data Collection from Insurers for Definition of EHBs
Practical Law Legal Update 1-520-5213 (Approx. 4 pages)
HHS Final Rule Addresses Data Collection from Insurers for Definition of EHBs
by PLC Employee Benefits & Executive Compensation
| Published on 23 Jul 2012 • USA (National/Federal) |
On July 20, 2012, the Department of Health and Human Services (HHS) issued final regulations identifying potential benchmark plans to support the definition of essential health benefits (EHBs). The regulations also establish a process for recognizing accrediting entities to certify qualified health plans for state health insurance exchanges.
On July 20, 2012, HHS issued final regulations establishing data collection standards addressing plan data to be collected from insurers of the largest three small group market products in each state, by enrollment, regarding covered benefits and plan identifying information. The data will support the definition of EHBs, which are ten general categories of items and services that, under the Affordable Care Act (ACA), must be offered beginning in 2014 by:
- Small group and individual insurance policies.
The final regulations, which finalize proposed regulations issued by HHS in June 2012 (see Legal Update, HHS Regulations Would Require Benefit Information from Small Group Plans), provide guidance to:
- Address the collection of data from certain insurers to define essential health benefits (EHBs).
- Establish a process for recognizing accrediting entities to certify qualified health plans (QHPs) for health insurance exchanges under the ACA.
The final regulations, which reflect 80 public comments received on the proposed regulations, include these changes:
- Modifying the definition of treatment limitations to:
- include only quantitative limits (for example, limits on the frequency of treatment and days of coverage); and
- exclude nonquantitative limits (for example, pre-authorization and step therapy requirements).
- Clarifying that the submission window for insurers begins on the final regulations' effective date (August 20, 2012) and closes on September 4, 2012.
- Establishing an exception to the general rule requiring accreditation for each product type offered by a QHP insurer (for example, exchange HMO or exchange point of service plan) if product type accreditation would not be methodologically sound (for example, if sample sizes are inadequate).
- Establishing the timeframe within which accrediting entities must provide current accreditation standards and procedures for performance measures to demonstrate that an entity meets the applicable conditions.
- Stating that recognized accrediting entities must provide HHS with 60 days' notice before public notification of any proposed changes or updates to accreditation standards and measurement procedures. The final regulations clarify that the accrediting entities need not provide the government advance notice of non-substantive error corrections.
Practical Impact
These final regulations are the latest in a lengthy series of HHS reports, bulletins and other guidance addressing the meaning of essential health benefits under the ACA. Earlier this month, HHS published guidance addressing the small group market products available for benchmark plan consideration in each state. Ultimately HHS will issue comprehensive regulations setting out which benefits are considered essential under the ten general categories listed in the ACA. The definition of essential health benefits is significant not only for plans and policies offered in the small and individual group markets, but also for the prohibitions and restrictions on lifetime and annual dollar limits, which apply to the value of essential health benefits (for more information, see Practice Note, Lifetime Limits, Annual Limits, and Essential Health Benefits Under the ACA).
According to the preamble to the final regulations, HHS will also issue additional guidance addressing the process for health plan accreditation, including recognition of accrediting entities.