Essential Health Benefits: Where Are We Now?

Although the presidential election was just last week, since President Obama won his re-election campaign HHS has wasted no time in moving forward on regulations to help implement provisions of the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148).Of course there are still ongoing legal battles regarding PPACA that are being fought in various parts of the country, which only adds to the complexity of the issues in front of Congress and the President.

According to Sam Baker and Elise Viebeck of The Hill’s Healthwatch column, HHS has submitted regulations to the Office of Management and Budget on essential health benefits, insurance regulations, wellness programs and quality initiatives. Essential health benefits were previously outlined by HHS as:

  • 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

PPACA requires that health plans that are offered to individuals and small group markets, in and out of insurance exchanges, offer a comprehensive package of services that include these essential health benefits. As we noted in October of this year, insurance policies must cover these benefits in order to be certified and offered in health insurance exchanges, and all Medicaid state plans must cover these services by 2014.

States have wiggle room when it comes to defining their own essential health benefits within each category, and earlier this fall they were asked to submit lists of their essential health benefits to the federal government. Arkansas, which formed a Plan Management Advisory Committee to create their list determined that prevention counseling for young women at a high risk for breast cancer was essential, and recommended a supplemental benchmark plan to include supplements for pediatric dental, pediatric vision as well as mental health and substance abuse services. States must also select a “benchmark” plan, with over 40 states selecting their plan at this point. So far the small employer plan has been the most popular benchmark plan, while Utah and Maryland selected state employer plans.

The definition of essential health benefits remains to be solidified, but it is an important area to keep an eye on in the coming months.