Since the passage of health reform (Affordable Care Act), many have wondered what would be covered in the benefits offered through the State Exchanges. We have been reassured that the benefits that are "essential" would be comprehensive yet affordable. But essential to whom? What is an essential benefit and who gets to decide? Tough questions. No easy answers.
Today HHS released a bulletin punting part of the issue to the States. States will have more "flexibility" to determine what is in the essential benefit package. Of course, not complete flexibility. These benefit plans MUST include, at least, the ten categories of benefits that are defined in the law. Those categories include:
Section 1302(b)(1) provides that EHB include items and services within the following 10 benefit categories: (1) ambulatory patient services, (2) emergency services (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services, including behavioral health treatment, (6) prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and wellness services and chronic disease management, and (10) pediatric services, including oral and vision care.
Do you see anything that is missing? Do you see anything in this list that a plan offered to an individual or small group in your state might NOT include? Look again. Item #7 -- "habilitative" services and devices;" and item #10 -- "pediatric services, including oral and vision care." These categories are not commonly found in the more restrictive plans offered to individuals and small groups. In fact, the concept of a "habilitative benefit" is not widely understood nor is there a common definition, particularly among private insurance pans. HHS acknowledges that some plans in a state might not include those services, so they are working on a way to better define these services and allow states the "flexibility" to get creative about how they offer these services. For people who may need help maintaining function not just regaining it, this is a process they should watch very carefully.
Here are some questions that you might want to know about what is unfolding:
1) Why give states more flexibility to define what services are essential? Is a person in Florida really all that different from a person in Nebraska? Are there diseases in Florida that do not occur in Nebraska? Not really. The idea of "state flexibility" is often proposed to mitigate political opposition and deflect charges that this is a government takeover of health care. But it probably won't work here, because the law actually does define what is essential -- the ten categories. And there is no real flexibility for states to drop an entire category.
2) The law says that benefits must be equivalent to a "typical employer plan." Who defines what is typical? Is there any such thing? Actually, HHS went to some trouble to try to figure that one out. They analyzed a variety of benefit packages in the states and determined that the real variation was not so much across the ten categories (except for habilitation and oral and vision care for kids), as in the cost sharing for these services. So states can vary cost sharing and they can also choose what a typical or "benchmark" plan will be -- it could be the largest commercial HMO plan in the state, the largest small group plan, or a state or federal employees plan. If a state declines or is unable to choose a benchmark, there is a default benchmark which the state must choose.
3) What if a service I need is not considered "essential?" Where does chiropractic care fall in the ten categories? What about acupuncture? In vitro fertilization? Contraception coverage? Contraception coverage WILL be considered essential (if it is FDA-approved). That question has already been asked and answered by HHS. As for other services, this will be a state by state decision.
4) If your state already mandates that certain services be included in the benefit packages sold in my state, what happens to those benefits? There are literally hundreds of state mandated benefits across the 50 states, and there is considerable variability. Only a few states mandate autism services; many more mandate chiropractic. But here is where HHS most definitely punted and even poked states a bit in the eye. Since there was no way that all state benefit mandates could be included in a benefit package that was still affordable, HHS left it to the states to pay for the mandates they had already passed -- and states have to include those mandates in the essential package, at least for the first few years of the Exchange. State mandates are a mixed bag. Some are lobbied by the providers themselves; others by consumers and families. If you are giving states flexibility about adding services, it makes sense that they should have to live by the decisions they have already made.
5) How did HHS define a "medical necessary" benefit? They apparently did not. Even though the Institute of Medicine report recommended that this term of art be based on evidence not just the judgment of an individual doctor, HHS has not yet issued their recommendations. You may never have encountered a denial from your health plan because the service you and your doctor requested was not considered "medically necessary." But it is important to understand how this term is used in your plan. Appeals are a worthless exercise if you, as a consumer, do not understand the process by which a plan determines what they will pay for.
What is good about what the essential benefits as we understand them now? For one thing, mental health and substance abuse services are considered essential -- and that means no annual or lifetime limits, just as with medical services (after 2014); maternity care is included and essential, and not all small group or individual plans include maternity care; children can get some vision and dental care; if you have had an accident and you need ongoing physical therapy, there is a chance you can continue to get coverage to maintain your level of physical ability. Also, if your state mandates coverage of services you value, like acupuncture or chiropractic care, those benefits will be included as well.
What's next for essential benefits? There is a comment period during which time any person or group can submit their opinions and questions to HHS. ( Public input on this proposal is encouraged. Comments are due by Jan 31, 2012 and can be sent to: EssentialHealthBenefits@cms.hhs.gov.) Sometime in 2012, HHS will issue final regulations. And then? Well, check out what is going on in your state. 2014 is not that far away.
Follow Linda Bergthold on Twitter: www.twitter.com/lab08
ortho-k therapy for kids?
dental impants instead of bridges?
insurance companies are profit centers, not health care providers.
the american system is absurd and needs reform.
A. Hopefully nowhere chiropractry is anti-scientific quackery.
B. Acupuncture is no more effective than a placebo
C. In vitro is the definition of an "elective" medical procedure. Plus its quite irresponsible in the first place. Natural selection should be allowed to run its course.
there is a place for the work they do to rehabilitate injuries as part of physical therapy.
you are just wrong.
the thinking you have provided is shallow and its tone is unjustifiably self-righteous.
Uninsured?........... Single Payer is the answer.
Unaffordable?....... Single Payer is the answer.
Unemployed?....... Single Payer is the answer.
Inaccesible?.......... Single Payer is the answer.
Worry Free?.......... Single Payer is the answer.
No paperwork?..... Single Payer is the answer.
No Middleman?.... Single Payer is the answer.
No profit motive?.. Single Payer is the answer.
Whatever's the question - Single Payer is the answer.
--------Â-Â------ Per capita costs for the year 2009 ----------Â------
United States........ $7,960 .... 100% of US per capita cost.
Canada................. $4,363 ...... 55% of US per capita cost.
France.................. $3,978 ...... 50% of US per capita cost.
Germany............... $4,218 ...... 53% of US per capita cost.
United Kingdom.... $3,487 ...... 44% of US per capita cost.
Japan.................... $2,878 ...... 36% of US per capita cost.
Using the Canadian model and applying their per capita cost to the US population, we could cover EVERYBODY AND SAVE over $3,597 per person per year.
Switch to Single Payer, save a TRLLION DOLLARS EVERY YEAR, cover every man, woman and child, have better outcomes and........
Thats' what we lose EVERY YEAR that we DON'T adopt a single payer/universal health care system as is available in most Western countries.
Say goodbye to insurance company profits and individual bankruptcies due to medical costs.
No Fuss. No Bills. Everybody covered.
That's Single Payer.
"Signing the letter were: Energy and Commerce Democrats Doris Matsui (CA) and Anna Eshoo (CA), Ways and Means members Mike Thompson (D-CA) and Ron Kind (WI), Democratic Congressional Campaign Committee Chair Steve Israel (NY), Rules Committee Ranking Member Louise Slaughter (NY), Appropriations member Lucille Roybal Allard (CA), education and labor member Mazie Hirono (HI) and freshman member Colleen Hanabusa (HI).
"Essential" is up to the individual patient or patient's family and will always depend on the circumstances. Bureaucrats and politicians should not be deciding what is essential.
Food and water are essential to life but govt does not provide those or define what is essential for all of us.
Central planning collapsed with the fall of Communism and is an antique in our current internet & info savy societies. Let this antique go.
How is a food stamp-like coupon going to prevent the doctor from charging for services rendered? If an office visit costs $125, then presumably the doctor will collect $125 worth of "health care stamps," just as a grocery store will take $2.00 worth of food stamps to pay for a $2.00 loaf of bread.
How is that going to "reestablish the doctor-patient relationship"? If poor people use Medicaid then they already see a doctor, presumably the same doctor if they choose, and Medicaid pays for it. What is there in the current system that prevents a doctor-patient relationship? The only way that happens is when people can't afford health care and go to free or reduced-price clinics, and therefore see whatever doctor is on duty that day.
I'm not sure you've thought these proposals through carefully, or else I don't understand where you think the savings will come from.
http://www.washingtonpost.com/blogs/right-turn/post/interview-with-rep-paul-ryan/2011/12/15/gIQAEqRlwO_blog.html
Talk about slow learners. Maybe this is the kind of thing that should have been thought about BEFORE the bill became law - but as Nancy Pelosi said, "We have to pass this bill so people can find out what's in it."
Next thing you know we'll learn that the dedicated taxes to fund Obamacare don't even cover the costs when businesses start dumping employees into the exchanges...
I know which I'd prefer.
Maybe at first. There's no guarantee it will stay that way. At least when the insurance companies are setting coverage you have the option of getting a different company - under the one-size-fits-all formula, that's no longer an option.
They didn't extend healthcare to 15 million Americans, they destroyed it for 300 million Americans.
http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/etc/graphs.html
http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries/
http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries/models.html
More choices do not translate to neither lowering health care cost nor healthier society.
About defining essentials benefits, it would be simpler to decide by first starting out with assumption of not having any benefits at all to start out with and preventive care at first. It's has been shown that it is more cost effective to spend on preventive care than reactive care.
Our diet has some to do with it and it started at young age. And if US congressmen and women believed pizza is vegetable, then God helps us all. It won't matter how many more private health insurance companies that we are going to have.
http://www.huffingtonpost.com/2011/11/16/pizza-vegetable-school-lunches-lobbyists_n_1098029.html
Here are two personal examples. I lived in a state that had strict regulation of insurance companies (since the 70's). They could not refuse to insure you, or charge you outrageous rates for pre-existing conditions. If you worked more than 19 hours a week, the employer paid your insurance in full. Insurance for your family could be bought at a reasonable price. I was insured there for over a decade, so under HIPAA, when I moved, I should have been able to get similar insurance at a similar price.
The insurance companies said they had nothing "similar" (BCBS in both states) so my rate would be almost 4 times what I had been paying for the family, just for my coverage. No pre-existing conditions would be covered, period. So four times as much, to cover almost nothing.
But, while I was still insured, I was in a wreck in another state while traveling, and Life-Flight was called. My insurance company refused to pay for the helicopter flight as they weren't sure it was necessary. I sent them a letter explaining I didn't have a choice. Then they said it didn't matter, because they don't cover those kinds of flights out-of-state.
We're just going to have to choose the "least bad" solution.
If people had access to prevention and treatment of illness BEFORE it becomes catastrophic or life threatening, that's what drives prices down.
e.g. diagnosing diabetes early and initiating treatment will cost a hell of a lot less than waiting until they get so ill they have circulatory problems and renal failure. Same with hypertension.
I know I've been an RN for 40 years.
This is the problem with high ded. insurance also. People cannot pay the high costs in the deductibles so they wait until they are seriously ill to get treatment.
On the other hand, if this goes the way it's expected to - that is, placing more and more of the costs on individuals, including low income seniors - then there'll be even more people dying of treatable illnesses, thus fewer people on SS and Medicare. If we go far enough in this direction, it's guaranteed to lower overall costs.
American healthcare delivery for people who cannot afford "Cadillac plans" is already cut to the bone. To cut it even further is simply the same as meeting them at the ER door and shooting them through the heart. Y'know... to save all that expense.
You give yourself away with a comment like yours. You should consider reading the article itself instead of just the headline. It's about requirements for levels of care that will be covered by health insurance plans, not about government unions.
The fact that NONE of those were offered is a pretty good indication that the American PEOPLE already lost. Because America makes decisions based on politics, and our politics are ruled by corporate interests.
In the end, I have no doubt the decisions will be made based on what is most profitable for those big businesses that run (and ruined) our health care industry. Not for the benefit of most of our people.
In Kansas, the rightwing governor has announced his plan to partially privatize Medicaid while cutting a huge chunk out of the funding. He claims that no one will actually lose benefits - because he plans to put all those Medicaid recipients to work. Apparently he thinks there are jobs out there that are going begging.
He's also ignoring the fact that 66% of Medicaid dollars are spent to keep the frail elderly or demented patients in nursing homes after their own funds run out. Much of the rest of Medicaid funding goes to children. My question is whether he's actually ignorant of these facts or whether he plans to make the cuts and then say, "Oops," and annouce that there'll be drastic cuts which will close down many nursing homes and boot seniors in need of 24/ skilled nursing care out into the streets or shove them off onto family members who aren't equipped to safely care for these fragile seniors.