On December 2, 2022, HHS published a request for information (RFI) soliciting public comments on various essential health benefits (EHB) issues under the ACA. This is the first time HHS has requested comments on updating the EHBs since it became effective in 2014. As health insurance needs have changed, such as the increase in the utilization of telehealth and awareness of mental health and substance use disorder services benefits in recent years, this RFI will assist the agency in gauging how current EHB requirements should be updated.
The ACA requires non-grandfathered fully insured small group plans (and individual plans) to cover all 10 categories of standard EHBs. While self-insured plans and fully insured large plans are not required to cover EHBs, the ACA requirements on the prohibition on annual or lifetime dollar limits and maximum out-of-pocket limits apply to plans' EHBs. States generally select their own EHB-benchmark plans, including covered benefits and limitations on coverage, which serve as a reference plan for benefits considered to be EHBs in the state. Self-insured plans define EHBs by selecting any state's EHB-benchmark plan or a Federal Employees Health Benefits Program benchmark plan. Employers with insured plans must use the benchmark plan of employer's contract/situs state.
The 10 categories of EHBs defined currently by HHS:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorder services (including behavioral health treatment)
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services (including oral and vision care)
In the RFI, HHS requested comments, including to what extent state EHB-benchmark plan documents should include additional guidance and descriptions (e.g., 'medically necessary transportation' vs. 'ground, water and air ambulance'). Moreover, the RFI asks for public input regarding any barriers to accessing services due to coverage or cost, including mental health, behavioral health, and substance use disorders, and to what extent telehealth impacts access. The RFI also asks questions about prescription drug categories, whether the EHB definition needs to be updated to account for changes in medical evidence or scientific advancement (including to advance health equity issues), how EHBs could be modified to address access gaps and the impact an expanded EHB definition has on cost.
Employers should be aware of this development. Those wishing to submit comments must do so by January 31, 2023, in accordance with the RFI instructions.