November 18, 2011
Under the health system reform law, one of the Department of Health and Human Services’ (HHS) most consequential challenges involves deciding how to define the essential benefits (listed below) that must be offered by all health plans in state health insurance exchanges.
- Ambulatory patient services
- Emergency services
- Hospitalization
- Laboratory services
- Maternity and newborn car
- Mental health and substance use disorder services, including behavioral heal treatment
- Pediatric services, including oral and vision care
- Prescription drugs
- Preventive and wellness services and chronic disease management
- Rehabilitative and habilitative services and devices
http://www.cms.gov/LegislativeUpdate/downloads/PPACA.pdf
Although a benefit may be covered, it does not mean the health insurance plans pay for it in every circumstance. Medicare follows an evidence-based approach for coverage determinations and Congress did not call for a definition of medical necessity in the reform law, calling it unnecessary. However, some medical societies voiced concern on this front. They warned that health plans frequently rule health services as not medically necessary unless they are supported by randomized controlled studies. “The health plan might not exactly say it, but essentially what they’re sayings is, ‘Occupational therapy for a child with cerebral palsy – where’s the evidence?” the AAP’s Dr. Racine said. Often, primarily concerning women’s health and pediatrics, few such studies exist. In these cases, it is apparent that alternatives as observational studies or specialty expert opinion should suffice.
November 9, 2011
In these next few posts, we will be discussing the ongoing debate concerning government drafting of what health insurance carriers must cover, which raises emotionally charged issues revolving around patient need, medical necessity, and cost control. Feel free to contact us if you have further questions.
Defining Essential Benefits: Generosity vs. Affordability
Under the health system reform law, one of the Department of Health and Human Services’ (HHS) most consequential challenges involves deciding how to define the essential benefits (listed below) that must be offered by all health plans in state health insurance exchanges.
- Ambulatory patient services
- Emergency services
- Hospitalization
- Laboratory services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral heal treatment
- Pediatric services, including oral and vision care
- Prescription drugs
- Preventive and wellness services and chronic disease management
- Rehabilitative and habilitative services and devices
http://www.cms.gov/LegislativeUpdate/downloads/PPACA.pdf
HHS’ final decisions will affect options for tens of millions of people who would obtain their individual or small-group coverage through private health insurance plans in the state exchanges. The Congressional Budget Office estimates the amount of people obtaining insurance on the exchanges will grow from 13.8 million (2014) to 29.2 million (by 2018).
An ongoing debate about this issue weighs out the pros and cons of generosity versus affordability. “The more generous you make the benefits, the more expensive it will be, and if it’s more expensive, perhaps access to insurance will be less,” said John Ball, MD, chair of the IOM committee. Large companies generally offer more benefits than smaller businesses. So, do you keep essential benefits comparable to small-group, mediocre plans or a large-group, much more generous plan? Contact our office for further discussion. Your opinion counts!
