HHS gets specific: ACA’s essential benefits

On the The Colbert Report this week, Stephen Colbert talked to a CEO who has written a book about our broken health care system. What Colbert concluded was that what we need is “basic cable” … not “premium cable.” Coincidentally, the U.S. Department of Health and Human Services (HHS) yesterday released its final regulation about what essential benefits the health reform law should include. What’s “basic” in health care is an issue of heated debate. Individuals and groups as diverse as cancer advocates, children’s hospitals, parents of disabled children, physical therapists, dentists, and optometrists have been waiting for final clarification from HHS. Will the services they value be included in the insurance plans you choose? If you missed this debate, there are some things you need to know.

Essentially good news

The good news is that within eight months (October 2013), you will be able to log on to a web site in your state and see what health plans will be offered individuals and small employer groups as of January 1, 2014. That is the date that these “marketplaces” or “exchanges” for health insurance will “go live” and you can sign up for a plan. (If you work for an employer with more than 50 employees that offers you benefits already, this does not apply to you … at least not yet. You probably already have access to all of these benefits.)

If you are an individual without insurance hoping to get coverage through the Affordable Care Act (ACA), what types of treatments and services will be included in the plans offered through these marketplaces? If you work for a small employer who has not yet been able to afford to offer you insurance coverage, the exchanges will help your employer provide insurance coverage to you and other employees. But what will you actually get from that insurance? That’s the big question.

The definition of ‘essential’

One of the most controversial issues about the ACA has been the definition of an essential benefit. There has been plenty of discussion about what “essential” really means. What services should be considered basic or “essential?” What treatments should be covered? Surgery? Doctor visits? Mental health services? What copays and deductibles would be acceptable? Will there be a limit to what you will have to pay out of your pocket AFTER you pay your premium?

These are pretty important questions and some were answered in the ACA. But until the Final Regulation was issued this week, the Act itself provided relatively little guidance about what “essential” means, other than to outline the following ten broad categories of services:

• ambulatory patient services
• emergency services
• hospitalization
• maternity and newborn care
• mental health and substance abuse disorder services, including behavioral health treatment
• prescription drugs
• rehabilitative and habilitative services and devices
• laboratory services
• preventive and wellness services and chronic disease management
• pediatric services, including oral and vision care

If you look at that list, it seems pretty comprehensive. Doctor visits (ambulatory) covered. Check. Hospital care covered. Check. Laboratory tests covered. Check. So far so good. Maternity care is not covered in every private plan today, so that’s a real benefit. Mental health and substance abuse services are not always covered. That’s a great addition, and this final regulation confirms the importance of these services. Preventive services are already being provided to everyone without copays, even though the definition of “prevention” is under attack, particularly in regard to women’s reproductive health.

Habilitative services, pediatric dental and vision

But the trickiest issues to define have been the “habilitative” services, and pediatric dental and vision services. These are benefits that are not always included in private plans. HHS asked for commentary from the public and received 11,000 comments, many of which were related to these more ambiguous categories.

The final regulation actually punted the decision about “habilitative”to the states to use either the current Medicaid definition or a definition by the National Association of Insurance Commissioners (NAIC). This is important for families of children with disabilities, because many private plans only cover physical therapy or other”rehabilitative” services that “restore” function but don’t necessarily maintain it.

For children or adults who need ongoing treatment, the category of “rehabilitative” does not include everything they need to stay healthy and even restore function. This is an issue in the regulation that HHS has promised to keep their eyes on, but families should most definitely continue to monitor what their states are doing and how HHS evaluates the actual implementation of this benefit.

For many families who already have insurance, including their children in their plan usually means that some vision or dental benefits will be available to those children. One of the peculiarities of the ACA is that these benefits were broken out separately and thus defining what should be included in a “children’s dental benefit” or “vision benefit” has been left hanging. This final regulation clarifies to some degree what such a benefit would look like.

Without getting too much into the weeds, the benefit will be consistent with what the “benchmark” plan in a state would offer – let’s say the largest small group plan in your state. In order to give states the so-called “flexibility” they said they needed to implement health reform, HHS has bent over backwards to give those states decision-making power over some of these important benefits. The downside of this “state flexibility” means that the largest small group plans in some states may be skimpy on the details of some of these categories.

The bottom line of the final regulation on “essential benefits” is that it didn’t change much from interim regulations issued last year. HHS did listen to some of the comments for change, but more often than not, they retreated to earlier regulatory advice, left definition to the states, or promised oversight in the future.

Keep your eyes on the essential prize

What this means for you and me is that we must keep our eyes on what emerges in October in our state when these plans are revealed.  If you live in a state that has refused to implement an exchange/marketplace for insurance, the federal government will do that for your state.  Most likely you will have access to a decent benefit offering similar to what federal employees now enjoy. (It’s  a puzzle to me why Republican-controlled legislatures in these states would want the federal government to administer this program, but I think their hostility to the ACA and unreasonable hope that it would never be implemented got them confused about their real interests.)

If you live in a state that is implementing the exchange themselves, you will want to take a close look at what the “default” or “benchmark” plan offers.  Isn’t it always true that it’s the details that matter?

The essentials of the ‘essentials’:

1. Not every specific service or treatment that you think should be defined as essential, either in the benefit package or by the medical director of your plan will be covered.
2. The real devilish details are described in the medical or clinical policies of the plan, and you can find those policies online for many insurers today.
3. There will inevitably be denials of treatment by the insurance plans. The process for appealing a plan decision should be clear and you will need to know how to use it.
4. One of the key ways to decide what is paid for and what is not is defined by the term “medical necessity.” HHS has not told insurers how they should define this term, but it is what medical directors of health plans use when they try to decide what to pay for. Learn about it.
5. Your insurance coverage through the health exchanges will not be free. But there are subsidies to help you pay for it. The best news about January 1, 2014 is that individuals and families without insurance will no longer have to worry about bankruptcy or avoid care because of the cost. It will be quite a relief to many Americans.