Standards related to Essential Health Benefits, Actuarial Value, and Accreditation
November 26, 2012
The Department of Health and Human Services (HHS) has published a series of proposed rules implementing several Affordable Care Act (ACA) insurance reforms, including Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation, which require consistency across health insurance options, ensuring that all plans cover a core package of items and services.
Essential Health Benefits (EHB):
The law ensures that health plans offered in the individual and small group markets, both inside and outside of Exchanges, offer a core package of items and services, known as the essential health benefits package. In addition to meeting the Actuarial Value requirements and cost-sharing limitations, a plan must include items and services within at least the following 10 categories known as essential health benefits (EHB):
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Pediatric services, including oral and vision care
- Preventive and wellness services and chronic disease management
The EHB Package is based on a state-specific benchmark plan. One of the options for selection as a benchmark plan is the largest small group health plan in the state. States select a benchmark plan and all plans must offer benefits that are equal to the benefits in the benchmark plan. In Iowa and South Dakota, Wellmark's Alliance Select Copayment Plus PPO and Wellmark's Blue Select PPO have been established as the benchmark plans. These plans must also include supplemental coverage of pediatric oral and pediatric vision.
Actuarial Value is calculated as the percentage of total average costs for covered benefits that a plan will cover. Non-grandfathered health plans in individual and small group markets must meet certain Actuarial Values, represented by metallic levels: 60 percent for a bronze plan, 70 percent for a silver plan, 80 percent for a gold plan, and 90 percent for a platinum plan.
Two agencies have been recognized by HHS as accrediting agencies to certify qualified health plans within the federal or state exchanges — The National Committee for Quality Assurance (NCQA) and URAC.
For a complete review of the proposed ruling, please see the attached document. Additional information on health care reform can be found on WeKnowReform.com.