HHS Issues Final Rule on Benchmarking EHBs for Insurance Exchanges

Margaret Dick Tocknell, for HealthLeaders Media , July 20, 2012

In response to comments received when this rule was first proposed, HHS has made several changes in the final rule, including:

  • Clarifiying that riders (optional or required benefits available for an added premium) should be included in data collected to identify benchmarks.
  • Excluding collecting data on prior authorization and/or step therapy for drug coverage.
  • Amending the definition of treatment limitations and data collection to include only quantitative limits.
  • Permitting NCQA and URAC to review policies and procedures at the issuer level provided they are uniform across the issuer's product line.
  • Clarifiying that network adequacy and access accreditation standards include "maintaining a network that is sufficient in number and types of providers to assure that services are accessible without unreasonable delay."
  • Removing essential community providers from the network adequacy standards for accreditation.
  • Modifiying data sharing requirements between accrediting entities and exchanges to specifically exclude personally identifiable data.
  • Establishing Sept. 4, 2012 as the submission deadline for insurers that are eligible to be the benchmark plan for EHBs.


Health insurance exchanges remain a political hot potato as some states balk at the federal mandate. Under PPACA, states must have insurance exchanges in place by 2014. According to the Kaiser Family Foundation at least 15 states are participating in the process while 18 are still studying their options.

If a state declines to set up its own exchanges, then HHS will step in and run the exchange. Alaska, Florida, and Texas are among a handful of states that plan not to operate their own exchanges.

Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
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