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Essential Benefits Update: Data Collection Standards

Posted on June 15, 2012 | No Comments

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Key Developments
Implementation Briefs

By Sara Rosenbaum


On June 5, 2012 the United States Department of Health and Human Services (HHS) published a proposed rule (77 FR 33133-33142) that would establish data collection standards for health insurance issuers as part of the Department’s implementation of the Affordable Care Act’s (ACA) essential health benefit provisions. Comments will be accepted until 5:00 p.m. on July 5, 2012.


Under the ACA, as of January 1, 2014 all health insurers selling policies in the individual and small group (under 100 people) health insurance markets must cover certain benefits classified under the law as “essential health benefits” (EHBs).[1] The EHB requirement applies regardless of whether the product is sold inside or outside state health insurance Exchanges. The ACA identifies 10 mandatory benefit categories encompassed within the EHB standard ((A) Ambulatory patient services, (B) Emergency services, (C) Hospitalization, (D) Maternity and newborn care, (E) Mental health and substance use disorder services, including behavioral health treatment, (F) Prescription drugs, (G) Rehabilitative and habilitative services and devices, (H) Laboratory services, (I) Preventive and wellness services and chronic disease management, and (J) Pediatric services, including oral and vision care).[2] The ACA further establishes certain actuarial values for the EHB product market, pegged to different “metals” levels (platinum, gold, silver, bronze) and sets special cost-sharing and deductible rules. The statute also (i) specifies that coverage must reflect that which is available through a “typical” employer plan; (ii) directs the Secretary of HHS to assure that coverage achieve an “appropriate balance” among the required coverage categories and take into account the health care needs of diverse segments of the population; and (iii) directs the Secretary to assure that coverage does not discriminate on the basis of disability, age, life expectancy, or degree of medical dependency and quality of life.[3]

The coverage parameters established under the ACA are thus broad. These parameters identify the categories of benefits that must be included, and set ground rules for design while also specifying minimum actuarial values that must be achieved. The law itself is silent on many aspects of coverage design: the definitions that must be used for the broad benefit categories; the governing medical necessity standard; the permissibility of coverage limitations (both quantitative and non-quantitative limits such as the use of fixed treatment limits or narrow practice guidelines in determining which treatments will be covered); and the use of coverage exclusions. This “fine print,” which is integral to any insurance policy or health plan, is central to determining the actual scope of coverage.

Guidance issued by HHS in December, 2011 and February, 2012 provides more extensive detail regarding the federal government’s interpretation of what the EHB coverage requirement means in actual implementation practice. Guidance published by HHS in January 2012 set forth an “illustrative list” of the largest three small group market products for each state.[4] In brief, the December HHS guidance: (i) delegates the specific design of EHB-governed products to states; (ii) requires states to select a “benchmark” from among four possible benchmark plan types; (iii) requires states to modify their selected benchmarks to reflect all 10 coverage categories in the event that the selected benchmark omits one or more categories of coverage and provides guidance on how states should go about the task of filling in a missing category; (iv) specifies the application of mental health parity to the EHB individual and small group market; and (v) permits EHB-governed products to engage in benefit design flexibility in order to vary specific aspects of coverage (e.g., capping benefits in one category while permitting more coverage in a separate category) plan from among products sold in their small group markets.

Even with this guidance, the precise scope and limitations of coverage under the EHB standards cannot be known with precision, because insurance products contain so many fine points and caveats. For this reason, and in order to allow for ongoing refinement of the EHB standard, HHS has proposed rules requiring additional reporting on the scope and content of EHB coverage under state benchmarks.


The Notice of Proposed Rulemaking (NPRM), which also sets forth standards for accrediting issues of Qualified Health Plans (QHPs), would establish the following data collection standards from certain health insurance issuers:

  • Who is affected? Health insurance issuers that offer the three largest health insurance products by enrollment in each state’s small group insurance market.
  • What data must be furnished? The issuers covered by the mandatory reporting requirement must furnish the following information: (1) administrative data necessary to identify the health plan that the issuer offers; and (2) data and descriptive information on the following items: (i) “all health benefits in the plan”; (ii) treatment limitations; (iii) drug coverage; and (iv) enrollment.
  • The NPRM Preamble notes that “any” treatment limitation must be reported.[5] With respect to drug coverage, issuers report their covered drug list as well as “information on whether each drug is subject to prior authorization and/or step therapy.”[6]
  • The Preamble also clarifies that stand-alone dental plans are covered by a voluntary reporting requirement only.
  • The Preamble further notes that “additional detail describing the specific data elements that issuers would submit can be found in the revision of the currently approved Health Insurance Web Portal information collection request (ICR).” The Department notes that there will be a separate notice and comment period on the ICR specifics.


  • Will the NPRM be understood to require information on both quantitative and non-quantitative treatment limits? This is the standard used by federal agencies in determining whether health plans are in compliance with federal mental health parity standards under the Mental Health Parity and Addiction Equity Act of 2008. That is, will insurers be required to report benefit definitions, treatment exclusions, and limitations on treatment linked to the practice guidelines that they use to inform their coverage decisions? HHS explicitly is “soliciting comment on other data elements that may be necessary to ensure that health plans offer EHB.”
  • Should information also be provided on other elements of plan design, such as certain provider network characteristics (for example, the conditions under which out-of-network providers may be used, with coverage remaining at in-network rates, or the inclusion of certain designated centers of excellence)?
  • Should plans be explicitly required to report on how they take health or disability status into account when making coverage decisions (for example, utilizing a full recovery standard when determining if a particular treatment will be considered medically necessary)?

[1] PHSA §2707, added by PPACA §1201.
[2] 42 U.S.C. §18022, added by PPACA §1302.
[3] 42 U.S.C. §18022(b)(4).
[4] 77 Fed. Reg. 33134.
[5] 77 Fed. Reg. 33136.
[6] Id.

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