Tag Archives: essential health benefits

How might healthcare reform 2.0 affect dental care benefits?

The Patient Protection and Affordable Care Act (ACA) made pediatric dental care an essential health benefit that issuers must offer on state exchanges. If proposed changes to the ACA are enacted, the dental benefits industry must again determine how to proceed in an evolving landscape. In this paper, Milliman’s Joanne Fontana discusses several key components of the ACA that, if amended or removed, would affect dental benefits. She also provides considerations for dental insurers that can turn another potential round of reform into opportunity.

IRS releases final rule on information reporting under the ACA

The Internal Revenue Service (IRS) has published two sets of final rules on the information reporting requirements of the Patient Protection and Affordable Care Act (ACA), providing guidance on the reporting of minimum essential coverage and of healthcare coverage. The minimum essential coverage reporting requirement under tax code Section 6055 applies to employers that sponsor self-insured group health plans, group health insurance issuers, and the boards of trustees, association, or committees of multiemployer plans that provide minimum essential coverage. The healthcare coverage reporting requirement under Section 6056 applies to large employers (with at least 50 full-time or equivalent workers, except that for 2015 only the threshold is 100 full-time or equivalent workers) that are subject to the ACA’s employer “shared responsibility” (also known as “pay or play”) provisions. In general, the reporting entities must collect the information beginning January 1, 2015, and include the information on a single, consolidated form submitted to the IRS and given to employees in 2016.

Separately, the Centers for Medicare and Medicaid Services (CMS) released a final rule governing insurance on the exchanges in 2015, but also providing guidance on the transitional risk reinsurance program (TRRP) fee that insurance issuers and self-funded plans must pay to help offset the costs of non-grandfathered individual coverage.

For Milliman’s perspective read this Client Action Bulletin.

State-by-state variation in essential benefits

The Patient Protection and Affordable Care Act of 2010 (PPACA) introduced a concept called essential health benefits (EHB), 10 categories of healthcare services that plans operating in the state health insurance exchanges must cover when the exchanges come online on January 1, 2014. In December 2011, the U.S. Department of Health and Human Services (HHS) issued a bulletin providing guidance on EHB. HHS issued more regulations last week.

HHS delegated to the states the responsibility for determining the essential benefits in their states, with some constraints. This initial approach by HHS (for plan years 2014 and 2015) is intended to help states phase in the market reforms. It allows some flexibility for states in the initial decision about which specific services will be covered as essential, but limits the choice to what is currently covered by major plans in the state and nationally. States must define their essential benefits during the third quarter of 2012, with varying progress to date. This paper reviews the state employee benchmark plans and provides an illustration of possible variation in essential health benefits by state.

Proposed regulations on EHB, actuarial value, and market rules

The U.S. Department of Health and Human Services (HHS) released three proposed rules with comment periods related to the Patient Protection and Affordable Care Act (PPACA) this week. The proposed rules can be accessed at the Federal Register.

Standards related to essential health benefits, actuarial value, and accreditation: 30-day comment period
Health insurance market rules; rate review: 30-day comment period
Wellness programs in group health plans: 60-day comment period

For additional information on proposed state essential health benefits benchmark plans, click here.

Essential health benefits requirements in final phase

The Centers for Medicare and Medicaid Services (CMS) recently submitted their final rules on essential health benefits for health insurance exchanges. The rules specify insurance plan requirements including the exchanges’ actuarial value, quality, and accreditation standards.

Here is an excerpt from Modern Healthcare:

Policy experts variously expect federal rules to provide states with more guidance about the minimum coverage that plans in state-run exchanges will need to offer their residents; offer approval or tweaks to minimum coverage requirements that some states have submitted to the CMS; and set minimum coverage levels of private plans included in federal exchanges.

The law established 10 essential benefit categories in which exchange plans will have to provide coverage, including preventive care, emergency services, maternity care and prescription drugs. But states can decide what benefits are included under those categories, and about half of the states submitted an essential health benefits plan to the CMS by a Sept. 30 deadline. The coming rules may provide federal approval of those states’ benefit packages or provide another chance to change them, according to policy experts.