Comments on Essential Health Benefits Data Collection Proposed
Insurers' Points: Health insurers say the data collection proposal
exceeds what is needed to establish coverage limits and is duplicative.
Consumer Groups' Points: Data should be collected to guarantee
insurers do not discriminate in their coverage.
By Sara Hansard
Health insurers objected to a number of parts of a proposed rule that would
require each state's largest small group plans to report benefit information in
comments filed July 5.
The proposed rule exceeds what is needed to establish coverage requirements
under the health care reform law, the Blue Cross and Blue Shield Association
said in its letter,
signed by Justine Handelman, vice president, legislative and regulatory policy.
“The data requested for identifying and defining [essential health benefits
(EHBs)] go far beyond information on benefits/covered services and include
information that is not relevant for a state in defining its EHB package,” BCBSA
Under a proposed rule published in the June 5 Federal Register, the
Department of Health and Human Services said the three largest small group
health insurance plans in each state would have to report enrollment and benefit
information to HHS (see previous article). The proposed rule also
outlines how data would be collected from stand-alone dental plans, and the
accreditation process for issuers of “qualified health plans” that will be
offered in the online exchange markets that begin operation in 2014.
The three largest small group plans in each state are among the choices that
states are likely to be able to use as benchmarks in establishing the so-called
essential health benefits that must be covered by all “nongrandfathered”
individual and small group plans--plans that existed prior to enactment of the
Patient Protection and Affordable Care Act on March 23, 2010. The Center for
Consumer Information and Insurance Oversight (CCIIO), part of the Centers for
Medicare & Medicaid Services, July 3 posted a list
of the largest three small group products by state on its website.
In December 2011, HHS issued a guidance bulletin giving states the option to
choose among plans that would be benchmarks for EHB requirements in each state.
If a state does not choose a benchmark plan on which to base EHBs, HHS said it
would choose as a default the largest small group plan in the state, based on
enrollment, for plan years 2014 and 2015. HHS said it intends to pursue a
rulemaking at an unspecified later time.
BCBSA said in its letter that it is concerned that HHS is requesting comments
on the EHB data collection process without issuing final guidance on the EHB
bulletin. “Issuers should not be expected to implement multi-million dollar
changes and conduct laborious data collection efforts based on informal guidance
that can be subject to changes in a final rule,” it said.
The June 5 proposed rule would take health insurance issuers “far in excess”
of the four hours estimated by HHS to compile the information requested, which
would include administrative data, covered health benefits, treatment
limitations imposed on coverage, and prescription drug coverage, including a
list of covered drugs and information on whether each drug is subject to prior
authorization and step therapy.
BCBSA suggested that HHS omit requirements that issuers submit information on
referral requirements, prior authorizations, treatment limitations, and
prescription drug formularies that are used to determine coverage, and ambiguous
“catch-all” categories. “There are literally thousands of variations of coverage
for any single insurer and the administrative burden of reporting all of the
situations under which prior authorizations, referrals or non-quantitative
limits are required would be significant,” it said.
In America's Health Insurance Plans' letter, signed by
Jeanette Thornton, vice president, health IT strategies, AHIP said the proposed
rule duplicates information already submitted to states and collected by HHS for
its Healthcare.gov Plan Finder website, which lists health insurance plans and
No information should be collected by HHS from issuers at this time unless it
is needed by states to determine whether all of the 10 general EHB benefit
categories are covered as required under PPACA, AHIP said. Once a state selects
an EHB benchmark plan, only that plan should have to report the data in the
proposed rule, AHIP suggested.
Consumer advocacy group Families USA said in its letter, signed by Lydia
Mitts, the group's Villers fellow, and Cheryl Fish-Parcham, deputy director,
health policy, that “robust data on the potential benchmark plans is vital to
better understanding how the Department's intended approach to defining the
Essential Health Benefits would impact the populations we represent.”
Data collection on benefit limits should be used to prohibit discriminatory
and overly restrictive treatment limitations from being incorporated into the
EHB package, Families USA said. HHS also should collect data on “rider”
policies--provisions purchased separately that cover additional
benefits--included in potential benchmark plans as well, it said.
Families USA expressed concern about the use of “wellness” programs, which it
said could be used “to circumvent other features of the Affordable Care Act,
such as the end to discrimination based on health status and gender.”
Wellness programs with incentives based on achieving health outcomes can be a
backdoor form of medical underwriting, the group said at a conference in January
(see previous article). Wellness programs should not be included in EHBs,
Families USA recommended that HHS require more data be collected on
quantitative and nonquantitative plan coverage limits, including the number of
people reaching each limit.
More detail is needed on a new alternative approach to select a state's
benchmark plan, the Center on Budget and Policy Priorities (CBPP) said in its letter, signed by Jesse
Cross-Call, policy associate; Sarah Lueck, senior policy analyst; and Edwin
Park, vice president for health policy.
“Until now it appeared that HHS envisioned two paths that a state could take
when selecting an EHB benchmark”--choosing its own benchmark plan or allowing
HHS to designate the largest small group plan in a state as the “default”
benchmark, CBPP said. Required benefit categories missing from the benchmark
plans would be filled in from other available benchmark plan options, it
Appendix G of the Health Insurance Web Portal, a template
HHS included with the proposed rule for plans to use to submit the data,
“suggests that HHS is developing a third path by which a state could designate
one of the small group plans as its benchmark and then leave it to HHS to ensure
coverage in all 10 required EHB categories,” CBPP said. HHS should provide more
information on how the new option would work, it said.
The Blue Cross and Blue Shield Association's letter is at http://op.bna.com/hl.nsf/r?Open=shad-8vxmcw.
The Center for Consumer Information and Insurance Oversight's Essential
Health Benefits: List of the Largest Three Small Group Products by State is
AHIP's letter is at http://op.bna.com/hl.nsf/r?Open=shad-8vxnj9.
Families USA's letter is at http://op.bna.com/hl.nsf/r?Open=shad-8vxnwz.
CBPP's letter is at http://op.bna.com/hl.nsf/r?Open=shad-8vxpdw.
The Health Care Reform Insurance Web Portal Requirements template is at