CMS, HHS, DOL, EHBs, OOP, ACA-OMG!

On February 20, 2013, a new round of rules was released by the Centers of Medicare & Medicaid Services (CMS), the Department of Health and Human Services (HHS) and the Department of Labor (DOL), collectively referred to as the "The Departments." 
Be aware of these three departments as we move towards implementation of ObamaCare.

Effective for new and renewing plans on and after January 1, 2014, all "Non-Grandfathered" fully insured small group and individual health plans must cover essential health benefits (EIBs). 

Also effective for new and renewing plan on and after January 1, 2014, all health plans, regardless of group size or funding type, must apply all member cost share for in-network srevices and out-of-network emergency services to the in-network out-of-pocket (OOP) maximum, which cannot exceed $6,350/$12,700. 

All copayments, coinsurance and deductible amounts for EHSs must apply to the out-of-pocket maximum.  No annual or lifetime dollar limits are allow on EIBs but other types of limits can be put in place, including:

• Visit limits
• Day limits
• Occurrence limits
• per episode or per service limits

EHB Categories of Benefits:

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  (Must cover the greater of either one drug in every US Parmacopea (USP) category and class, or the same number of prescription drugs in each category and class as the EHB-Benchmark plan.
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-services for individuals under the age of 19.

Large group and self-funded (ASO) health plans do not need to offer all of these 10 categories of Essential Health Benefits, or meet actuarial value requirements that non-grandfathered small group and individual policies have to meet.  The rule is still important to large group and self-funded (ASO) plans because they are subject to many rules tied to EHBs such as:

• The out-of-pocket maximum applies to EHBs
• EHSs covered by a large group or self-funded (ASO) plan cannot have annual or lifetime dollar limits.