Final Rule for the Exchanges Issued

The EDC continues to both monitor and influence the implementation of the Affordable Care Act.  On February 20, 2013, the Administration offered the Final Rule for the Exchanges.  Here is our summary of this rule.

The Affordable Care Act (ACA) requires that all of plans offer a core of benefits, known as the EHB. HHS has issued a final rule on the Essential Health Benefits (EHB’s)--see the full regulation here.  The EHB’s must include services in:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

Benchmark Plans

Because of the provision in the ACA that requires the EHBs to be equal in scope to benefits offered by a typical employer plan, the final rule states that all plans offer benefits equal to the benefits offered by the benchmark plan. They must cover mental health services at parity. However, the plans can substitute benefits within a category (excluding prescription drug benefits) as long as the substitution is actuarially equivalent. The final rule defines EHB based on a state-specific benchmark plan. States can select a benchmark plan from among several options, including the largest small group private health insurance plan by enrollment in the state.

The benchmark plan options include: (1) the largest plan by enrollment in any of the three largest products by enrollment in the state’s small group market; (2) any of the largest three state employee health benefit plans options by enrollment; (3) any of the largest three national Federal Employees Health Benefits Program (FEHBP) plan options by enrollment; or (4) the HMO plan with the largest insured commercial non-Medicaid enrollment in the state.

Twenty-six states selected their own benchmark and the final rule states that if the remaining states that do not make a selection, HHS will select the largest plan by enrollment in the largest product by enrollment in the state’s small group market as the default base-benchmark plan. The selected benchmark plans are already finalized for benefit year 2014.

The final rule provides guidance on how the state will supplement the benchmark if the plan is missing any of the ten categories of benefits. The provisions for supplementing are the base-benchmark plan where it does not adequately cover any of the ten categories of EHB.  Plans can not include discriminatory benefit designs and must ensure a balance among EHB categories

Parity:

The statute requires that all plans covering EHB offer mental health and substance abuse

service benefits, including behavioral health treatment and services.  Coverage of EHB must provide parity in treatment limitations between medical and surgical benefits and the mental health and substance abuse benefits required to be covered as EHB in both the individual and small group markets. 

Approximately ninety-five percent of those with coverage through the three largest small group products in each state had mental health and substance abuse benefits. According to the final rule, “a study of implementation of parity in the FEHBP plans as well as research into state-passed mental health parity laws have shown little or no increase in utilization of mental health services, but found that parity reduced out-of-pocket spending among those who used mental health and substance abuse services.”   

Next Steps:

As the ACA is implemented and as the Exchanges go live in 2014, it is essential that we ensure that all mental health services are covered at parity in each of the states and that all levels of care are covered. We need to continue to advocate at both a state and federal level to ensure people with eating disorders are able to receive the treatment and care that they both need and deserve.

Please see our benchmark survey to better understand the coverage of eating disorders in the benchmark plans. To understand how the Exchanges are being implemented in your state, see this interactive map from the Kaiser Family Foundation.