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Final Rule on Data Collection for Essential Health Benefits Unveiled

By Jane Norman, CQ HealthBeat Associate Editor

July 19, 2012 -- The Obama administration recently disclosed the contents of a final rule dealing with information that insurers must provide as part of the health law's standard health benefit package, less than two weeks after the comment period for the proposed regulation ended.

The speed with which the rule was rolled out is an indication of how quickly federal officials are moving now that the Supreme Court upheld the health overhaul law and deadlines loom for implementation of health benefits exchanges and the formation of the plans they will offer.

While the rule is not a major piece of how essential health benefits will be administered, in its proposed form it nonetheless stirred objections among insurers who said it went too far by asking them to describe not only the services they cover, but how they plan to limit access to covered services.

The requests were excessive, could cause competitive issues and could limit the flexibility that insurers have in designing their plans, insurers said.

Essential health benefits are the standard services that individual and small group plans must provide consumers under the health care law (PL 111-148, PL 111-152). States will be allowed to choose among various plans already in existence as benchmarks for setting their minimum benefits. This rule spells out what information plans that are potential benchmarks must provide to the government to help in the definition of standard benefits.

In the final rule, Health and Human Services did make some changes from its first proposal. It said, for example, that the agency initially proposed that insurers must specify whether their covered drugs are subject to prior authorization—approval from plans before they are paid for—or "step therapy," under which one drug must be tried before another is covered.

"In response to comments received on this proposal, we no longer intend to collect data on prior authorization and/or step therapy for drug coverage," HHS said.

The agency also rebuffed requests from consumer advocates for information to be gathered beyond what it had proposed. "Many commenters requested that HHS collect data in addition to the elements listed in the proposed rule, such as data on exclusions, medical necessity, habilitative services, cost-sharing (including premiums and co-pays), additional drug data, additional data on treatment limits, and a more extensive list of benefits," the agency said.

"We believe the data collection proposed balances a minimal data collection burden on issuers while being sufficient to support the establishment of a potential benchmark for each state. Therefore, we are not requiring issuers to report any additional data elements in this final rule."

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