Under guidance issued since Affordable Care Act (ACA) implementation, qualified health plans must provide coverage for specific benefit categories called essential health benefits (EHB). CMS is seeking public comment addressing various aspects of EHB covered by qualified health plans under ACA requirements. Comments must be received by January 31, 2023. Submission guidance and additional detail can be found here.

States are responsible for defining benefits under EHB-benchmark plan design, and the EHB fall within ten categories:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Pregnancy, maternity and newborn care
  • Mental health and substance use disorder services
  • Prescription drugs
  • Rehabilitative and habilitative services
  • Laboratory services
  • Preventive and wellness services
  • Pediatric services

CMS seeks comment on the following:  

  • Benefit descriptions in EHB-benchmark plan documents
  • Benefits provided under a typical employer plan
  • Review of EHB related to:
    • Whether consumers experience significant barriers to access behavioral health services
    • Strategies to broaden access to telehealth
    • Effective methods to control costs of EHB
    • Whether and how to update EHB based on medical evidence and scientific advancement
    • EHB design and how to address health equity issues and gaps in coverage
  • Coverage of prescription drugs as EHB
  • Substitution of EHB

Contact ATTAC Consulting Group to learn how our compliance experts can help your plan assess the impacts of proposed changes.