HHS Releases Final Regulations on Essential Health Benefits Standards

On February 20, 2013, the Department of Health and Human Services (HHS) released a final rule that helps consumers shop for and compare health insurance options in the individual and small group markets by promoting consistency across plans, protecting consumers by ensuring that plans cover a core package of items that are equal in scope to benefits offered by a typical employer plan, and limiting their out of pocket expenses.

The Final Rules include details on:

• Essential Health Benefits (EHB) benchmark and default plans
• Determining Actuarial Value (AV) and Employer Mandate Minimum Value (MV)
• Preventive care
• Cost sharing requirements

Starting January 1, 2014, non-grandfathered insurance plans in the individual and small group market and those in the exchanges will be required to provide EHBs. Most of the EHBs are services already covered by most health plans, such as hospitalization or pharmaceuticals, but some, such pediatric oral and dental care, are not commonly covered and thus represent a coverage expansion. The EHB requirement will also improve mental health coverage in the individual and small group market, as noted in a brief released with the final rule.
 

The HHS also published the Actuarial Value (AV) calculators for determining the of individual and small group plans and for determining whether large employer health plans meet the minimum value requirement of the employer responsibility provision, as well as the final EHB base-benchmark plans for each of the states. The minimum value calculator, published for comment, will be used to determine whether a large employer plan provides 60 percent actuarial value. If a large employer health plan fails to meet this requirement, employees who are otherwise eligible for premium tax credits may receive them through the exchange, and if employees do so, the employer will owe a penalty.

Anthem Fact Sheet Published 4/3/2013