The state-level flexibility will come with strict limits, according to the HHS guidance (PDF). Specifically, the only existing plans that could serve as a state essential benefit “benchmark” are one of the state's three largest small group plans; one of its three largest state employee health plans; one of its three largest federal employee health plans; or the largest HMO plan offered in the state's commercial market.
However, any plan selected by a state must cover all 10 required categories of care or the state will have to select coverage of the uncovered categories from other benchmark insurance plans, such as the Federal Employee Health Benefits Plan. The 10 categories of care include preventive care, emergency services, maternity care, hospital and physician services, and prescription drugs.
“Our approach will protect consumers and give states the flexibility to design coverage options that meet their unique needs,” Sebelius said in a written statement.
Additionally, plans could modify coverage within a benefit category so long as they do not reduce the value of coverage.
The cost-sharing aspects of such plans will be addressed in future bulletins, according to the HHS guidance.
Additionally, the rules will require states to pay for any coverage they require insurers to provide that are beyond their essential benefits package.
HHS officials declined to provide a timeline for either the proposed or final rules for essential benefits packages, during the Friday press call.
In a separate letter to governors, Sebelius said the Friday guidance was in response to their requests for information on the essential benefit packages by the end of 2011. While HHS released this information bulletin to offer guidance to states in advance of the legislative sessions many will begin in January, the agency still expects to proceed with the full rulemaking process for essential benefits, an HHS official told Modern Healthcare.
Although the law will require all plans to offer the same essential benefits package, the degree to which the different plans require beneficiary cost-sharing will determine whether they are ranked as bronze, silver, gold or platinum plans.
The coming rules reflected October recommendations of the Institute on Medicine, which urged, in part, that HHS balance the cost and comprehensiveness of the essential benefits by reflecting existing plans in the small employer market.
Separately, HHS officials said they are watching the growth of self insured plans among small employers, which are not subject to the essential benefit rule, and may take future actions to regulate those.
