Final Federal Rules on Essential Health Benefits Released

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On Wednesday, the Department of Health and Human Services issued its final rule on essential health benefits, a major component of the Affordable Care Act. Essential health benefits include ten categories of healthcare services--such as hospitalizations, prescription drugs, and emergency services--that many health care plans in states' individual and small group markets, including but not limited to plans offered through the new state health insurance marketplaces, will be required to offer.


In terms of requirements about prescription drug coverage, the final ruling is not much different from previously issued guidelines. Health care plans will still be required to cover at least one drug per category, or the number of drugs per category in the state's chosen benchmark plan, whichever is greater. Additionally, the final ruling includes a strengthened requirement that insurers must set up procedures that allow patients to get access to prescription medications that are not covered by their plan, if those medications are appropriate for the patient.

The final ruling also continues to leave many details about essential health benefits up to the states. As states make these decisions, we hope they focus on providing individuals in their state with access to the robust prescription drug coverage they deserve.