HHS to Shift More Control to States to Implement Health Care Reform
On December 16, 2011, the U.S. Department of Health and Human Services (“HHS”) released its “Essential Health Benefits Bulletin,” which provides the states with more flexibility in implementing the Affordable Care Act (“ACA”). The ACA mandates that non-grandfathered health plans offered in individual and small group markets, both inside and outside of the state exchanges, offer a comprehensive package of “essential health benefits” in at least ten categories of care. While the ACA lists the ten categories of care (including, e.g., preventive care, emergency services, maternity care, hospital and physician services, and prescription drugs), it does not specify what services must be provided within each category. HHS has shifted these decisions to the individual states. Under the approach outlined in the Bulletin, states would be permitted to select an existing health plan as the benchmark for the services included as “essential health benefits” from among the following:
One of the three largest small group plans in the state;
One of the three largest state employee health plans
One of the three largest federal employee health plan options; or
The largest HMO plan offered in the state’s commercial market.
This approach will be effective only for a transition period of 2014 and 2015. In 2016, HHS will evaluate the benchmark approach and may determine which state-mandated benefits are essential or not essential. HHS is seeking public comments on this Bulletin by January 31, 2012. Self-insured group health plans, large group insured plans, and grandfathered plans are not subject to the essential health benefit requirements. For more information about essential health benefits or the ACA, please contact your Trust Fund counsel.
Author: Kristina Zinnen
