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HHS/CMS RIN: 0938-AR03 Publication ID: 2012 
Title: Patient Protection and Affordable Care Act; Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation (CMS-9980-F) 
Abstract: This final rule details standards for health insurance consistent with title I of the Affordable Care Act. Specifically, this rule outlines Exchange and issuer standards related to coverage of essential health benefits (EHB) and actuarial value (AV). This rule also proposes a timeline for qualified health plans to be accredited in Federally-facilitated Exchanges and an amendment that provides an application process for the recognition of additional accrediting entities for purposes of certification of qualified health plans. 
Agency: Department of Health and Human Services(HHS)  Priority: Economically Significant 
RIN Status: Previously published in the Unified Agenda Agenda Stage of Rulemaking: Proposed Rule Stage 
Major: Yes  Unfunded Mandates: No 
CFR Citation: 45 CFR 156    45 CFR 155    45 CFR 147   
Legal Authority: PL 111-148, title I   
Legal Deadline:
Action Source Description Date
Final  Statutory    01/01/2014 

Statement of Need: This rule sets forth standards related to EHB and AV consistent with the Affordable Care Act. HHS believes that the provisions that are included in this rule are necessary to fulfill the Secretary's obligations under sections 1302 and 1311 of the Affordable Care Act. Establishing specific approaches for defining EHB and calculating AV will bring needed clarity for States, issuers, and other stakeholders. Absent the provisions outlined in this rule, States, issuers, and consumers would face significant uncertainty about how coverage of EHB should be defined and evaluated. Similarly, failing to specify a method for calculating AV could result in significant inconsistency across States and issuers. Finally, establishing a clear timeline for potential qualified health plans to become accredited is essential to successful issuer participation in Federally-facilitated Exchanges.

Summary of the Legal Basis: The provisions that are included in this rule are necessary to implement the requirements of title I of the Affordable Care Act.

Alternatives: None. This is a statutory requirement.

Anticipated Costs and Benefits: HHS anticipates that the provisions of this rule will assure consumers that they will have health insurance coverage for essential health benefits, and significantly increase consumers' ability to compare health plans, make an informed selection by promoting consistency across covered benefits and levels of coverage, and more efficiently purchase coverage. This rule ensures that consumers can shop on the basis of issues that are important to them such as price, network physicians, and quality, and be confident that the plan they choose does not include unexpected coverage gaps, like hidden benefit exclusions. It also allows for some flexibility for plans to promote innovation in benefit design. HHS anticipates that the provisions of this proposed regulation will likely result in increased costs related to increased utilization of health care services by people receiving coverage for previously uncovered benefits.

Risks: If this regulation is not published, the Exchanges will not become operational by January 1, 2014, thereby violating the statute.

Action Date FR Cite
Notice  09/14/2011  76 FR 56767   
Comment Period End  10/31/2011    
NPRM  11/26/2012  77 FR 70644   
NPRM Comment Period End  12/26/2012 
Regulatory Flexibility Analysis Required: Undetermined  Government Levels Affected: Federal, Local, State, Tribal 
Small Entities Affected: Businesses, Governmental Jurisdictions, Organizations  Federalism: Yes 
Included in the Regulatory Plan: Yes 
RIN Data Printed in the FR: No 
Agency Contact:
Leigha Basini
Health Insurance Specialist
Department of Health and Human Services
Centers for Medicare & Medicaid Services
Center for Consumer Information and Insurance Oversight, MS: 733H.02, 7500 Security Boulevard,
Baltimore, MD 21244
Phone:301 492-4380