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CCH® BENEFITS — 06/11/12

HHS Proposes Rule On Data Collection To Support Standards For Essential Health Benefits

from Spencer’s Benefits Reports: The Department of Health and Human Services (HHS) has issued a proposed rule that would establish data collection standards necessary to implement aspects of the Patient Protection and Affordable Care Act (ACA), which directs HHS to define essential health benefits (EHB). The proposed rule outlines the data on applicable plans to be collected from certain issuers to support the definition of EHB. Also, the proposed rule would establish a process to recognize accrediting entities to certify qualified health plans (QHP). The rule was published in the June 5 Federal Register.

Beginning in 2014, all non-grandfathered health plans in the individual and small group market, Medicaid benchmark and benchmark-equivalent plans, and Basic Health Programs, where applicable, will cover the EHB, as defined by HHS. The ACA directs that the EHB reflect the scope of benefits covered by a typical employer plan and cover at least ten general categories of items and services.

These general categories of items and services are:

1) ambulatory patient services;
2) emergency services;
3) hospitalization;
4) maternity and newborn care;
5) mental health and substance use disorder services, including behavioral health treatment;
6) prescription drugs;
7) rehabilitative and habilitative services and devices;
8) laboratory services;
9) preventive and wellness services and chronic disease management; and
10) pediatric services, including oral and vision care.

ACA Sec. 1302(b)(4) establishes that HHS must define the EHB such that it:

• sets an appropriate balance among the ten general categories;
• does not discriminate based on age, disability, or expected length of life;
• takes into account the health care needs of diverse segments of the population; and
• does not allow denials of essential benefits based on age, life expectancy, disability, or degree of medical dependency and quality of life.

Previous guidance. HHS has provided information about EHB in several phases, including a bulletin released on Dec. 16, 2011, which outlined its intended regulatory approach for defining EHB. The bulletin considered an intended approach in which EHB would be defined by a benchmark plan selected by each state. This state-specific benchmark plan would serve as a reference plan, reflecting both the scope of services and any limits offered by a “typical employer plan” in that state as required by the ACA.

In the bulletin, HHS laid out four potential benchmark plan types for 2014 and 2015. They are:

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 Employees Health Benefits Program plan options by enrollment, and
4) the largest insured commercial non-Medicaid health maintenance organization (HMO) operating in the state.

On Jan. 25, 2012, HHS released an illustrative list of the largest three small group market products by state. Then on Feb. 17, 2012, HHS further clarified the approach described in the bulletin through a series of Frequently Asked Questions.

Issuers required to report. The proposed rule includes data reporting standards for health plans that represent potential state-specific EHB benchmarks. Specifically, the proposed rule would establish that issuers of the largest three small group market products in each state must report information on covered benefits.

Required information. Under the proposed rule, relevant issuers would be required to submit the following information:

1) administrative data necessary to identify the health plan;
2) data and descriptive information for each plan on the following items:

(i) all health benefits in the plan;
(ii) treatment limitations;
(iii) drug coverage; and
(iv) enrollment.

Plans impacted. Issuers of the largest three products in each state would be required to provide information based on the plan with the highest enrollment within the product under the proposed rule. Issuers may use their own data to determine which plan within each product has the highest enrollment, although we expect for many products, the benefits will be the same across plans within the product. Enrollment data should reflect a plan’s entire service area and, to the extent possible, should align with the timing of the http://www.HealthCare.gov data collection (reflecting enrollment as of March 31, 2012).

Reporting requirements. Relevant issuers would be required to submit the required information to HHS in a form and manner that HHS specifies. HHS intends to make available publicly as soon as possible information on final state selections of benchmarks so that issuers can use it for benefit design and rate setting for 2014. In addition, HHS seeks public comment on this approach.

Voluntary data collection from stand-alone dental plans. Beginning in 2014, QHPs and other non-grandfathered health insurance plans in the individual and small group market will offer the EHB. ACA Sec. 1302(b) outlines the ten statutory benefit categories, including pediatric oral care, which must be included by those plans. ACA Sec. 1302(b)(4)(F) allows QHPs in an Exchange in a state to choose not to offer coverage for pediatric oral services provided that a stand-alone dental benefit plan that covers pediatric oral services is offered through the same Exchange.

For QHPs to know whether their plan design must include pediatric oral services, issuers need to know if stand-alone dental plans would be offered through their Exchange. To facilitate and streamline the communication of this information, HHS proposes to collect, on a voluntary basis, information from likely stand-alone dental issuers to find out whether various Exchanges are likely to have stand-alone plans as options. Therefore, HHS requests that issuers that intend to offer stand-alone dental plans in any Exchange notify HHS of their intent to participate. HHS intends to provide further guidance that explains the format and date by which stand-alone dental issuers can begin to submit this information.

Accreditation of qualified health plans. The rule also proposes the first phase of a two-phased approach for recognizing accrediting entities to implement the standards for QHPs to be accredited on the basis of local performance on a timeline established by the Exchange. In phase one, the National Committee for Quality Assurance (NCQA) and URAC would be recognized as accrediting entities on an interim basis. In phase two, a criteria-based review process would be adopted through future rulemaking.

Comments must be received by July 5, and may be submitted electronically at http://www.regulations.gov; or by regular mail to: CMS, Department of Health and Human Services, Attention: CMS-9965-P, P.O. Box 8010, Baltimore, MD 21244-8010.

For more information, contact Adam Block at (301) 492-4392 or Deborah Greene at (310) 492-4293.

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