Health Insurers, Consumer Groups Spar Over EHB Data HHS Needs to Collect

Stay ahead of developments in federal and state health care law, regulation and transactions with timely, expert news and analysis.

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 said.

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.

CCIIO Posts List of Largest Small Group Plans.

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.

HHS Burden Estimate Too Low.

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.


“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.”  


--Justine Handelman, Blue Cross and Blue Shield Association

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 Plan Finder website, which lists health insurance plans and their features.

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 Groups Want 'Robust Data.'

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.

Concerns About Wellness Programs.

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, it said.

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.

Detail Needed on Alternative Approach.

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 said.

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.

By Sara Hansard  

The Blue Cross and Blue Shield Association's letter is at The Center for Consumer Information and Insurance Oversight's Essential Health Benefits: List of the Largest Three Small Group Products by State is at AHIP's letter is at Families USA's letter is at CBPP's letter is at The Health Care Reform Insurance Web Portal Requirements template is at

Request Health Care on Bloomberg Law