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HHS Regulations Would Require Benefit Information from Small Group Plans
Practical Law Legal Update 8-519-7592 (Approx. 4 pages)
HHS Regulations Would Require Benefit Information from Small Group Plans
by PLC Employee Benefits & Executive Compensation
| Published on 05 Jun 2012 • USA (National/Federal) |
The Department of Health and Human Services (HHS) proposed regulations would require insurers of the three largest small group insurance products in each state to report certain coverage and enrollment information to HHS. The regulations also propose interim recognition of two agencies, the National Committee for Quality Assurance (NCQA) and URAC, as the entities that will accredit qualified health plans.
On June 4, 2012, HHS issued proposed regulations that would, among other things:
- Require insurers of the three largest small group insurance products in a given state to report certain information to HHS, so that plans offered in the state will have information on what essential health benefits (EHBs) will be available.
- Propose recognizing two agencies on an interim basis, the National Committee for Quality Assurance (NCQA) and URAC, as the entities that will accredit qualified health plans (QHPs).
- Allow HHS to collect, on a voluntary basis, information for stand-alone dental plans.
Reporting Information on Covered Benefits and Enrollment
Under the Affordable Care Act (ACA), starting in 2014, all insurers offering non-grandfathered health plans in the small group and individual markets must ensure that the coverage includes EHBs, as defined by HHS. EHBs must:
- Include the ten general benefit categories stated in the ACA (for example, emergency services and maternity care).
- Be equal in scope to the benefits provided under a typical employer plan.
The proposed regulations are intended to collect information on the benefits under benchmark plans so that other plans seeking to offer coverage in the small group and individual markets will know what benefits will be included in the EHB benchmark. The proposed regulations would require insurers of the three largest small group products by enrollment in each state to report information on covered benefits and enrollment. This information would be used by HHS, states, insurers and health insurance exchanges to define, evaluate and provide EHBs. The required information would include:
- Identifying information for the insurer's health plan.
- Descriptive information addressing all health benefits in the plan.
- Data on any treatment limitations imposed on coverage.
- Information on drug coverage, including a list of covered drugs and information on whether each drug is subject to pre-authorization.
- Plan enrollment data.
The requested information would be submitted in a form to be determined by HHS. In future guidance, HHS will make information regarding its final state selections of benchmarks publicly available.
Accrediting QHPs
The ACA requires that health plans, in order to be certified as QHPs, be accredited on the basis of clinical quality measures. In the preamble to the proposed regulations, HHS states that establishing an interim period for certification is necessary to meet current timelines for establishing exchanges. HHS proposes to recognize NCQA and URAC on an interim basis to accredit QHPs, subject to certain conditions. Among these conditions is a requirement that NCQA and URAC accredit plans based on several categories, which include quality assurance, network adequacy, and complaints and appeals.
HHS is soliciting comments on:
- Whether entities in addition to NCQA and URAC are eligible to be accrediting entities.
- The standards for clinical quality measures, including whether additional standards should be used.
- Whether HHS should require entities seeking recognition as accrediting entities to review specific clinical measures.
Under the proposed regulations, an accrediting entity would be required to provide separate accreditation determinations for each product type (for example, exchange health maintenance organization, point of service and preferred provider organization) offered by a QHP in each exchange.
QHP insurers must authorize the accrediting entity to release certain materials related to QHP accreditation to HHS and exchanges, including:
- Identifying information of the QHP insurer.
- The insurer's accredited product line and types that have been released.
- Additional information, including product identifiers, accreditation status and score, expiration date of accreditation, and clinical quality results at the level specified by the exchange.
Voluntary Collection Regarding Stand-alone Dental Plans
Under the ACA, QHPs can choose not to offer pediatric oral care as an EHB provided that a stand-alone dental benefit plan covering pediatric oral care is offered through the same health insurance exchange. The proposed regulations request that insurers that intend to offer stand-alone dental plans in any exchange notify HHS, on a voluntary basis, of their intent to participate in an exchange. This collection is intended to assist insurers who need to know whether stand-alone dental plans will be available through their exchange.
Practical Impact
The proposed regulations are the latest in a series of guidance in recent months, including reports and FAQs, addressing the meaning of EHBs for purposes of the health exchanges and other ACA requirements. Ultimately, HHS will issue comprehensive regulations addressing the meaning of EHBs, though the proposed regulations do not offer a timeframe for when that guidance can be expected.
URAC is also responsible for accrediting independent review organizations under the ACA's external review rules (for more information, see Practice Note, External Review under the ACA).
For more information on health insurance exchanges, see Practice Note, The Health Insurance Exchange and Related Requirements under the ACA.