Health Care Reform Primer: The Essential Health Benefits Package

It's been a week since my last post about the federal Patient Protection and Affordable Care Act, and during that week a federal judge in Florida ruled that the provisions in Section 1501(b) make the entire law unconsitutional. The Obama Administration has vowed to appeal the judge's ruling, and most pundits believe that the U.S. Supreme Court will eventually settle the question. Under the assumption that the PPACA will remain the law of the land (or at least part of the land) unless and until the nation's highest court rules otherwise, I plan to continue my review. I hope you'll stay around for the ride.

Last time, we had just gotten into the requirements for establishment of qualified health plans and had looked at the definition of a qualified health plan in Sect. 1301. Let's turn now to the requirements for the "essential health benefits package." The law defines this term as meaning coverage that 1) provides essential health benefits; 2) limits cost-sharing for the coverage; and 3) provides "bronze," "silver," "gold" or "platinum" levels of coverage. I'll get into what that means in another post.

The Department of Health and Human Services must define "essential health benefits," but the benefits have to include at least these categories and items and services within them:

• 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
• Pediatric services, including oral and vision care.

HHS must ensure that the scope of these benefits is equal to the scope of benefits provided under a typical employer plan. The Labor Department will take a survey of employer-sponsored coverage to determine typical benefits and report its findings to HHS so that agency can make an informed determination. HHS has to report to Congress that actuaries have certified that the essential benefits meet this requirement. When setting and revising the list of essential benefits, HHS must provide public notice and give the public opportunity for comment.

When designing the essential benefits package, HHS

• Must ensure that the list of essential benefits is not unduly weighted toward any one category
• May not design the benefits in ways that discriminate against individuals based on age, disability or life expectancy
• Must take into account the health care needs of diverse segments of the population, including women, children, and the disabled
• Must ensure that no one can be denied essential health benefits against their wishes due to that person's age, life expectancy, present or predicted disability, degree of medical dependency, or quality of life (NOTE: This provision shows that the "death panels" story is a myth.)
• Must provide that a qualified health plan must cover emergency services without requiring pre-authorization, limiting coverage for use of out-of-network providers, or increasing cost-sharing for use of out-of-network providers
• Must treat plans offered on exchanges the same, whether or not they provide stand-alone dental benefits, and
• Must periodically review the essential health benefits and report to Congress on whether enrollees are having trouble getting needed services due to coverage or cost; whether the list of essential health benefits needs updating; how the list will be modified to address gaps in access or changes in evidence; how additional or expanded benefits will increase costs; and
• Must periodically update the list of essential health benefits.

Nothing in the law prohibits health plans from providing benefits greater than those listed in the essential health benefits package.

Next time, we'll look at the requirements for cost-sharing provisions in health plans and how the maximum cost-sharing amounts will adjust each year.

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Comments

[Lance B JOhnson]

Are organ transplants considered essential health benefits?

[Tim Dodge]

Lance,
It doesn't appear that organ transplants fall into any of the essential health benefits categories. That doesn't mean that a plan won't cover them; it simply means that a plan can be sold on a health insurance exchange without covering them. Some plans may provide this coverage, others may not. This will be one more wrinkle in the competitive landscape.

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I was impressed as I read this blog. They prioritize first the top needs of the people. Health benefit packages one of the best that their government has done. Thumbs up for their country!

[lavalampexperiment]

thank you