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Update: Data Collection Standards Under the Essential Health Benefits Final Rule

Posted on September 5, 2012 | No Comments

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Key Developments
Editor's Comment
Implementation Briefs

By Nancy Lopez


On July 20, 2012, the United States Department of Health and Human Services (HHS) published a final rule[1] establishing data collection standards for health insurance issuers as part of HHS’s implementation of certain aspects of the Patient Protection and Affordable Care Act’s (ACA) essential health benefit provisions.[2] As discussed in an earlier brief, the ACA requires all health insurance issuers selling policies in the individual and small group markets to cover 10 mandatory benefit categories, classified as “essential health benefits” (EHBs) and defined by the Secretary of HHS.[3] In addition, EHBs must reflect the scope of benefits covered by a typical employer.[4]

HHS issued guidance on its intended approach to defining EHBs in December 2011 and February 2012. On June 5, 2012, HHS published a proposed rule (NPRM) on data collection standards.[5] This Update discusses the final rule which codifies the majority of the provisions in the NPRM, with only minor substantive changes. The final rule also establishes standards for accrediting entities to certify qualified health plans (QHPs), as required under the ACA.[6]

Modifications in Final Rule

Data Collection Standards:

  • In response to comments, HHS changed the definition of “treatment limitations” in the final rule to include only quantitative limits and removed the proposed requirement for insurance issuers to provide data on non-quantitative limits, such as prior authorization and step therapy requirements.[7]
  • HHS also noted in the Preamble that a “portal plan” may include riders if those benefits are part of the most commonly purchased set of benefits within the product by enrollment.
  • The Preamble clarified that applicable issuers can submit data until September 4, 2012.[1]
  • The final rule also codifies the proposed rule that issuers of the largest three small group market products in each state (health plans that represent potential state-specific benchmark plans) submit a report to HHS on covered benefits by September 14, 2012. The report must include:
    • Administrative data necessary to identify the health plan; and
    • Data and descriptive information for each plan on the following items:
      • All health benefits in plan;
      • Treatment limitations;
      • Drug Coverage; and
      • Enrollment.[9]
  • The Preamble noted that HHS intends to publish “state-specific benchmarks for notice and comment.”

Accreditation of QHP Issuers:

  • The final rule establishes that the National Committee for Quality Assurance (NCQA) and URAC are recognized as accrediting entities on an interim basis. HHS will implement a criteria-based review process to be adopted through future rulemaking.[10]

[1] Department of Health and Human Services. Final Rule: Data Collection to Support Standards Related to Essential Health Benefits; Recognition of Entities for the Accreditation of Qualified Health Plans, 77 Fed. Reg. 42658 (July 20, 2012).
[2] 42 U.S.C. §18022, added by PPACA §1302.
[3] PHSA §2707, added by PPACA §1201.
[4] 42 U.S.C. §18022, added by PPACA §1302.
[5] 77 Fed. Reg. 33133-33142 (June 5, 2012).
[6] 42 U.S.C. §18031, added by PPACA §1311; 45 C.F.R. §156.275.
[7] 45 C.F.R. §156.120(a).
[8] 77 Fed. Reg. 42661..
[9] 45 C.F.R. §156.120(b).
[10] 77 Fed. Reg. 42662-42663.

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