Essential Health Benefits (EHB) Comments


The ACA requires an EHB benchmark plan be established for each state. In accordance with the act, the benefits in the benchmark plan must be included in all non-grandfathered plans sold in the individual and small group markets, both inside and outside of the exchanges, beginning in 2014. Self-insured group health plans, grandfathered plans, and health insurance coverage offered in the large group market are not required to cover the EHB.
 
The act also requires each state's benchmark plan to include all items and services within the following 10 benefit categories:
  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, and
  10. Pediatric services, including oral and vision care.
In a bulletin issued on December 16, 2011, the U.S. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight (HHS / CCIIO) indicates each state has an opportunity to select its benchmark plan from the following 10 options:

  • The three (3) largest, by enrollment, small group insurance plans
  • The three (3) largest, by enrollment, state employee health benefit plans
  • The three (3) largest, by enrollment, national federal employees health benefit plan options, or
  • The largest, by enrollment, commercial non-Medicaid HMO operating in the state.
Selecting Services
In the event the benchmark plan chosen by a state does not contain all of the items or services required in the 10 EHB benefit categories, the state must also select services from other eligible plans to complete the benchmark. States must defray the cost of benefits required by state law in excess of essential health benefits for individuals enrolled in any plan offered through an exchange.
 
If no EHB benchmark plan is selected by the deadline set by HHS / CCIIO, the default benchmark plan for South Carolina would be the largest small group plan by enrollment, and HHS / CCIIO would select the additional services required to complete the EHB plan.
 
The South Carolina plans that may be considered for the benchmark, along with additional information related to the state's selection of the EHP plan, are linked below.
 
All comments and correspondence should be emailed to the South Carolina Department of Insurance no later than noon on September 25, 2012. Once the comments are reviewed and the additional information we requested from HHS / CCIIO is received by our agency, we will finalize the analysis.
 
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