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On Monday, Dec. 16, the U.S. Department of Health and Human Services (HHS) released a bulletin outlining guidance to states on implementing Essential Health Benefits (EHBs).  As you may recall, the Affordable Care Act will require individuals to have insurance coverage by 2014.  Individuals and business may purchase health insurance in a state based “health insurance exchange”.  All health plans offered through the health insurance exchange will be required to offer the EHBs.  The bulletin lays out  HHS’s recommendation that a state’s health insurance exchange be  based on employer-sponsored coverage in that state’s market.  The bulletin provides states with maximum flexibility by proposing that each state select a benchmark plan to define the EHBs.  This benchmark plan would reflect the scope of services offered by a “typical employer plan” in that state, but also would highlight services that a typical employer plan does not cover.  HHS lists four types of plans that could serve as benchmark plans in 2014 and 2015:

  • The largest plan by enrollment in any of the three largest small group insurance products in the state’s small group market;
  • Any of the largest three state employee health benefit plans by enrollment;
  • Any of the largest three national FEHBP plan options by enrollment; or
  • The largest insured commercial non-Medicaid Health Management Organization (HMO) operating in the state.

HHS announced this approach after seeking input from the Institute of Medicine (IOM), the public and the Department of Labor.  HHS intends to propose that if a benchmark is missing categories of benefits, the state must supplement the missing categories using the benefits from any other benchmark option.  Health insurance companies will have some flexibility to adjust benefits.

Since HHS has decided to let states decide EHBs, instead of creating a federal EHBs standard, many fear that states will continue the status quo or even have low EHBs standards because of costs concerns.  The federal government will subsidize coverage based on the essential health benefits, any coverage options above that standard states will have to pick up the cost.

It is important to evaluate how your state ranks regarding insurance coverage and benefits provided for patients with bleeding disorders.  Whether or not there are protections in place, continued advocacy is still necessary.  State advocacy of all stakeholders involved in this process: Legislators, Exchange Boards, Insurance Departments, Executive Branch, etc. will be crucial.

HHS is accepting public comments on the bulletin by Jan 31, 2012. The regulatory process for EHBs will likely continue into the year, guidance on calculating actuarial value, cost sharing and the provision of minimum value by employer-sponsored coverage will be released later, with more opportunities for public comment.

Read HHS press release here.

Read the Bulletin here.

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