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HIX Data Reporting Should Rely On 'Benchmark' Plans

The Department of Health and Human Services' proposed rule would clarify 'essential benefits' in state health insurance exchanges (HIXs) ahead of enrollment.

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The Department of Health and Human Services (HHS) wants to better define the "essential benefits" that non-grandfathered health plans participating in the state health insurance exchanges must offer. Its recently proposed regulations would accomplish that goal, as well as name two interim certification bodies to approve the plans seeking to participate in these exchanges.

Under the 2010 Affordable Care Act, all of these insurance plans must offer an essential benefits package that includes benefits in specific categories. But in December 2011, HHS told the states that they could determine what those benefits would be by using a "benchmark" plan in their state in one of four categories. If a state doesn't do so, HHS said, it intends to propose that the default benchmark plan be the largest plan by enrollment in the small-group insurance market.

The current proposal requires the issuers of the three largest small-group insurance products in each state to report certain information to HHS. The purpose of collecting this data now is to inform other plans seeking to offer coverage in the state insurance exchanges which benefits they would have to cover.

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Specifically, HHS wants the issuers of the potential benchmark plans to report administrative data that identifies the plans, as well as data and descriptive information on:

--Covered benefits

--Treatment limitations

--A list of covered drugs, along with information on whether each drug is subject to prior authorization and/or step therapy

--Plan enrollment data for their highest-enrollment plans

To make sure that the plans in the exchanges meet government requirements, HHS also named two organizations as interim accreditors. Both of these entities--the National Committee for Quality Assurance (NCQA) and URAC--already accredit health plans. HHS said it is selecting them now so that they can begin approving health plans early next year. To participate in the exchanges in 2014, health plans will have to start enrollment by fall of 2013.

Among the categories of benefits that plans in the insurance exchanges must cover are ambulatory patient services; emergency services; hospitalization; maternity and newborn services; mental health and substance abuse services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Many states have not begun building insurance exchanges, and others are encountering difficulties because of health IT challenges. As Politico recently reported, the state insurance exchange systems must be able to communicate with other state and federal information systems, but the interfaces have not been built. Also, the state exchanges will need tax information to determine the eligibility of individuals for insurance subsidies, but the federal data hub needed to provide that data to the states does not exist yet.

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