DEPARTMENT OF INSURANCE
May 2, 2013
Qualified Health Plan Requirements
Substitution of EHBs
This bulletin is directed to all insurers writing accident and health insurance policies, as defined by IC 27-8-28-9
, in the nongrandfathered individual and small group market; health maintenance organizations, as defined by IC 27-13-1-19
; risk retention groups, as defined by IC 27-7-10-11
; reciprocals, as provided by IC 27-6-6-1
; fraternal benefit societies, as provided by IC 27-11-1-0.3
; and rating organizations, associations, and all other entities making accident and health product filings subject to the Patient Protection and Affordable Care Act (ACA). The purpose of this bulletin is to provide guidance on Indiana's rules regarding Essential Health Benefits (EHBs).
45 CFR 156.115(b) permits a state to limit or prohibit EHB substitutions. The Department hereby prohibits EHB substitutions for plan years effective on or after January 1, 2014. The Department will reassess this rule for subsequent plan years.
However, this EHB substitution prohibition is not applicable to prescription drug benefits coverage. 45 CFR 156.122 requires a plan to cover at least the greater of (i) one drug in every United States Pharmacopeia (USP) category and class; or (ii) the same number of prescription drugs in each category and class as the EHB-benchmark plan. By meeting either of the prescription drug benefit requirements, the health plan satisfies this EHB provision and is not considered a prohibited substitution.
Permissible Benefit Limits
Generally, limits on the dollar amount of benefits are prohibited by ACA. However, the three benefits listed below, as part of the state's EHB benchmark plan, will maintain their dollar limit quantity and do not have to be converted to actuarially equivalent treatment or service limits as part of 45 CFR 147.126. Health plans are permitted to maintain these limits as part of their plan's benefit design and satisfy EHB requirements.
|Benefit ||Limit Quantity
|Dental Services for Accidental Injury and Other Related Medical Services ||$3,000
|Human Organ and Tissue Transplant Services - Transportation and Lodging ||$10,000
|Human Organ and Tissue Transplant Services - Unrelated Donor Search ||$30,000
Questions regarding this bulletin should be directed to Erin Mathies, Deputy Commissioner of Insurance Policy, at (317) 234-7732 and firstname.lastname@example.org or email@example.com.
INDIANA DEPARTMENT OF INSURANCE
Posted: 05/08/2013 by Legislative Services Agency
Composed: Dec 22,2014 8:37:12AM EST
version of this document.