HHS proposes rule to help define essential health benefits

To comply with the Affordable Care Act, states must now select plans that address 10 categories of care.

The Health and Human Services Department on Friday detailed its proposed options for states to use in selecting the "essential health benefits'' they are required to offer individuals and small groups by 2014 under the 2010 Affordable Care Act.

As described in a bulletin released for public comment, states preparing to implement health insurance exchanges are to select the benchmark for their plans -- all of which must include 10 categories of basic care set out in the law. States will choose among typical plans offered by either 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 health maintenance organization plan offered in the state's commercial market.

"Under the Affordable Care Act, consumers and small businesses can be confident that the insurance plans they choose and purchase will cover a comprehensive and affordable set of health services," said HHS Secretary Kathleen Sebelius. "Our approach will protect consumers and give states the flexibility to design coverage options that meet their unique needs."

In a conference call with reporters, she added that "what works in Florida may not work in Nebraska."

States can modify the plans as long as they don't reduce the overall value, and they must offer preventive care, emergency services, maternity care, hospital and physician services, and prescription drugs. Since states will be required to finance any benefits over and above the essentials, they will be given a transition period during which HHS can monitor progress.

Sherry Glied, assistant HHS secretary for planning and evaluation, said more than 30 million Americans who are newly insured in 2014 will have a comprehensive benefit.

"Many millions of Americans buying their own insurance today will gain valuable new coverage," she added, "including more than 8 million Americans who currently do not have maternity coverage and more than 1 million who will gain prescription drug coverage."

Glied said the benchmark approach is similar to that featured in the State Children's Health Insurance Program and parts of Medicaid. Most employer packages are similar, she said, the differences falling mostly in coverage of areas such as pediatric vision and dental care.

Steven Larsen, deputy administrator and director of the HHS Center for Consumer Information and Insurance Oversight, told reporters the release was made this month because "states are interested in knowing how we approach this as they come into their legislative seasons."

The proposed rules deal only with benefits being offered to individuals and small groups, not with cost sharing policies such as deductibles and co-payments, which will be addressed separately. Comments are due Jan. 31, 2012.