New info on Essential Health Benefits

Today the federal government released new info (cms ehb proposed rule 11 20 12) on the Essential Health Benefits selection process. Please the following message from Stacey Pogue of the Center for Public Policy Priorities about this development.

“CCIIO just released the federal EHB rule for private market plans (attached) and guidance on EHB in Medicaid.  Relevant links to rules/guidance and summaries of a few points below. Texas’ benchmark is listed as the small employer BCBSTX plan since (as far as I know) Texas did not submit a choice.  Link to overview of benefits in that plan below. Comments on the rules and the state benchmark are due by Dec 20.  Texas has until Dec 20 to make an EHB benchmark selection.

The rule is lengthy.  If you don’t want to read it all, I suspect that we’ll be able to find summaries of the rule in the next 24-48 hours.  I usually find good summaries at these two websites: and

CCIIO also release separate rules today for workplace wellness programs and 2014 market reforms (no pre-existing conditions, can’t charge small employers more, etc).

CCIIO factsheet on EHB rule:

The proposed rule also includes a number of standards to protect consumers against discrimination and ensure that benchmark plans offer a full array of EHB benefits and services. For example, the proposed rule:

  • Prohibits benefit designs that could discriminate against potential or current enrollees
  • Includes special standards and options for health plans for benefits not typically covered by individual and small group policies today, including habilitative services
  • Includes standards for prescription drug coverage to ensure that individuals have access to needed prescription medications.

The appendix of the proposed regulation includes the proposed list of state-selected EHB-benchmark plans, as well as the default benchmark plan for state that does not select a benchmark plan, for public comment. States can make an EHB-benchmark selection until the close of the comment period for this rule.

Proposed rule:  Attached to this email and also at CMS-9980-P: Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation

Plan details for Texas’ default benchmark:   For all states:

Today, HHS also provided guidance to State Medicaid programs laying out how existing private plans in Medicaid will have to meet the standards of the Essential Health Benefits provision. The guidance can be found here:

Habilitative Services

The habilitative services category may be empty in an EHB-benchmark plan.  As proposed in section 156.110(f), if the base-benchmark plan does not include coverage for habilitative services, the state would, under our proposal, be able to determine which services are included in that category.   If the base-benchmark plan does not offer habilitative services and the state does not make that determination, then as proposed in section 156.115(a)(4), the issuer would be able to determine which habilitative services to offer.

Mental Health Parity

The benchmark plans displayed may not comply with the mental health parity standards.  However, as described in proposed section 156.115(a)(2), mental health parity would, under our proposal, be required for compliance with EHB standards.

Prescription Drug EHB-Benchmark Plan Benefits by Category and Class

Please note that in some cases a category is listed without a class because there are some drugs within the category that have not been assigned to a specific class.

Please also note that where the benchmark plan does not include coverage in a United States Pharmacopeia (USP) category and class, pursuant to proposed section 156.120, one drug would have to be offered in that USP category and class.

In conjunction with the proposed policy that plans offer the greater of one drug or the number of drugs in the benchmark, HHS is considering developing a drug counting service to assist states and issuers with implementation of the proposed prescription drug policy.”


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