Guidance Describes Essential Health Benefits and Coverage Offerings

Posted by BAS - 21 February, 2013

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Yesterday, the Department of Health and Human Services issued a final rule describing standards related to essential health benefits. Health care reform requires all non-grandfathered health insurance coverage in the individual and small group markets (both in a health care Exchange and outside an Exchange) to cover what the government deems essential health benefits beginning January 1, 2014.

Essential health benefits fall into 10 general categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Plans in the individual and small group markets must also meet specific actuarial values, called "metal levels" (60 percent for a bronze plan, 70 percent for a silver plan, 80 percent for a gold plan, and 90 percent for a platinum plan) to help consumers compare and select coverage among comparable benefit offerings.

While the new rule makes few changes to previously issued guidance, it does clarify some items:

  • Pediatric services means services for individuals under the age of 19 years, but states have flexibility to extend pediatric coverage beyond the 19-year age baseline;
  • Mental Health and Substance Abuse benefits are considered essential health benefits that must be covered under a plan;
  • An insurer may not discriminate based on an "individual's age, expected length of life, present or predicted disability, degree of medical dependency, quality of life or other health conditions; and
  • Insurers must offer at least one drug per therapeutic category, or the same number as a state's benchmark plan, whichever is greater.

The guidance also addresses specific issues related to the required coverage of preventive services without cost-sharing.

  • If a colonoscopy is scheduled and performed as a covered screening procedure, the plan or issuer cannot impose cost-sharing for the cost of a polyp removal during the colonoscopy.
  • The coverage of genetic counseling and evaluation for routine breast cancer susceptibility includes both the BRCA gene testing and the follow up counseling.
  • A plan or issuer should use clinical expertise to identify individuals in a high-risk population for determining which services should or should not be covered without cost-sharing.
  • At least one annual well-woman visit for preventive care for adult women must be covered to the extent that the visit provides age- and developmentally-appropriate services, including preconception and prenatal care.
  • Preventive services include screening and counseling for interpersonal and domestic violence.
  • The coverage for annual HIV counseling and screening for all sexually active women includes the actual testing for HIV.
  • Breastfeeding and lactation counseling are considered preventive health services.

The new guidance is intended to expand coverage offerings in the individual and group health plan markets while making it easier for consumers to compare health plans.

Topics: Health Care Reform (ACA)


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