Health Center Regulatory Issues, Uncategorized

CMS Releases Essential Health Benefits Bulletin

By: Susan Sumrell

On December 16, 2011 CMS’ Center for Consumer Information and Insurance Oversight (CCIIO) released a bulletin on the Essential Health Benefits. This bulletin outlines CCIIO’s intentions in defining Essential Health Benefits, as required by the Affordable Care Act (ACA). CCIIO is soliciting comments on this bulletin by January 31, 2012.

In the bulletin, CCIIO outlines the background and statutory authority in the ACA to establish the Essential Health Benefits (EHB) and the process for the development of the proposals. Section 1302(b)(1) of the ACA lists the 10 benefit categories that the EHB must include: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse disorder services, including behavioral health treatment, 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.

Additionally, the bulletin outlines CCIIO’s intended regulatory approach, which provides States with flexibility, suggesting that EHB be defined by a benchmark plan selected by the States. This approach gives States flexibility in choosing one of four benchmark plans: the largest plan by enrollment in any of the three largest small group insurance products in the State’s small group market, any of the largest three State employee health benefit plans by enrollment, any of the largest three national FEHBP plan options by enrollment or the largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the state. The bulletin notes that if one of the 10 benefit categories is missing from the chosen benchmark plan, it must still be covered by health plans that are required to offer EHB.

NACHC is reviewing the Bulletin and will be submitting comment to CMS. Comments are due January 31, 2012 and can be submitted to We hope to have a draft of our comments to share by January 21 and we encourage PCAs and health centers to review the Bulletin and submit comments as well. We also welcome any suggestions or responses you may have to our draft comments.