Tuesday, May 7, 2013

ACA update: essential health benefits

By Emily McKinley, Health Information Specialist

As the full implementation of the Affordable Care Act (ACA) draws nearer (January 2014), final rules and regulations are being issued by the Department of Health and Human Services (HHS). In February, the final rule on Essential Health Benefits (EHB) was issued. Before we discuss the details of that rule, let’s review.

One of the most important provisions of the ACA is the inclusion of EHB. These are categories of benefits and services that insurance plans must include. There are ten categories of essential health benefits, they are:
  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care
Because some of these categories have previously been excluded by insurers (to include the benchmark plans in many states) and are often rather ambiguous in interpretation, HHS examined them more closely and issued a final rule. The final rule primarily discusses mental health and substance use disorder services, prescription drugs, pediatric dental services, and habilitative services.

Advocates across the nation celebrated the inclusion of mental health and substance use disorder services as an EHB category. It is estimated that more than 60 million individuals will now have access to treatment for these illnesses and disorders, which were previously sidelined if not altogether ignored by insurers. Further, states are not required to pay for this added benefit in the cases where benchmark plans did not already have provisions for it.

The ruling regarding prescription drug benefit remained largely unchanged. Simply, plans must include at least one prescription drug offering from each category and class in US Pharmacopeia’s guidelines. Additional drugs may also be offered without a cost to the state.

Advocates were less supportive of the final rule regarding pediatric dental benefits. These benefits have been difficult to include in the legislation, and the final rule allows a separate out-of-pocket maximum for pediatric dental benefits. Also, while the benefits must be offered, consumers are not required to purchase these services. Thus, there is concern about the overall affordability and access of these benefits for children.

Additionally, the final ruling was not as definitive as many had hoped with regard to habilitative services. While the inclusion of these benefits is seen as a large win for vulnerable populations, especially individuals with special health care needs, there is still room for improvement. Because many benchmark plans do not currently cover habilitative services, this is another category that lacks clear definition and market standards. Further, the ruling allowed states to opt out of defining habilitative services while providing insurers the opportunity to do so. Insurers may define the services by mirroring that of the rehabilitative services offered or may altogether define the habilitative services and their scope and report that to HHS. This allowance has many wondering how broad or comprehensive habilitative services will truly be.

Lastly, while dollar limits in regards to insurer responsibility are no longer allowed, insurers may impose non-dollar limits to care, to include a limited number of a particular services (therapy visits, for example), days in the hospital, and others to benefit categories.

Advocates and critics alike are concerned about the vague language with which HHS has chosen to move forward, and there is real concern whether Americans will receive the coverage intended by the legislation. For that reason, it is important to note that these benefits and definitions of each are in effect for 2014 and 2015. HHS will review the benchmark approach as well as recommendations for revisions to implement in 2016.

For more information about the ACA, we recommend visiting www.healthcare.gov, where you can find more information on this and other provisions of the ACA. To discuss how the ACA or other healthcare systems and policies affect you and your family, please contact Family Voices at info@fvindiana.org or 317.944.8982.  

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