Thursday, February 21, 2013

Final Rule on Essential Health Benefits Issued

The Final Rule on essential health benefits (EHBs), which describes the parameters of plans that will be included in the federal and state health insurance exchanges mandated by the Affordable Care Act (ACA), was published yesterday by the Department of Health and Human Services (HHS), and APA is encouraged by several modifications and clarifications from an earlier version. Of particular interest to psychiatrists and their patients is that the Final Rule confirms that the federal mental health parity law will apply to nongrandfathered small group and individual plans that are not self-insured. There is also a mandate for inclusion of mental health and substance abuse services.

In addition, in comments submitted to HHS in December 2012, APA urged a better floor for prescription drug coverage, one that follows Medicare Part D's "all or substantially all" standard, which requires plans to include six classes of prescription drugs. HHS did not accept such a broadening of the standard, sticking with its proposed mandate that an EHB's prescription drug category include the greater of one drug per class or what is currently covered in a given state's prescription drug category for its EHB benchmark plan. It did, however, provide for EHB plan beneficiaries to engage in an appeals process with their plan issuer when seeking a "clinically appropriate" medication not covered by their EHB benchmark plan. The Final Rule also states that when a state's benchmark EHB plan doesn't have a mental health and substance abuse disorder services category, HHS will require the state to supplement this category with a mental health and substance abuse category from another HHS-approved benchmark plan.

Commenting on the Final Rule, HHS Secretary Kathleen Sebelius said that, not only will the ACA's insurance exchanges help more people get the health care they need, but it will soon be "easier to compare and enroll in health plans with better coverage, greater quality, and new benefits."

(image: SVLuma/


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