HHS Proposes Framework for Meeting Essential Health Benefits Requirement Under Affordable Care Act
On December 16, 2011, the Department of Health and Human Services’ Center for Consumer Information and Insurance Oversight (CCIIO) released an essential health benefits bulletin (pdf) that describes a proposed regulatory approach that the HHS will use to define essential health benefits (EHB) under the Affordable Care Act. The health care reform law requires that, beginning in 2014, health plans offered in the individual and small group markets, including those to be offered in the future health insurance exchanges, provide a package of benefits and services considered “essential.” While the Act does not specify the EHBs that must be covered by each plan, it does state that as of January 1, 2014, non-grandfathered plans in the individual and small group market and those in the exchanges must provide coverage of benefits or services in the following 10 categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. In addition, the Act mandates that the scope of EHBs must be equal to the scope of benefits provided under a “typical” employer plan.
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