HHS has issued its long awaited bulletin on essential benefits. The feds will allow states to decide on the scope of health plan benefits provided in their state as long as they allow for benefits in 10 defined categories. These include the benefits that are already covered under most medical plans, including inpatient and outpatient medical services, prescription drugs, maternity care, preventive care, lab services, emergency services and care for mental illness.
Also included are a couple of items that may not appear in most health policies. The mandate to cover pediatric care is also accompanied by a requirement that pediatric dental and vision services be provided. The directive also includes a mandate for rehabilitative and “habilitative” services. Rehabilitative services are directed toward regaining lost abilities. Whereas, habilitative services are aimed at attaining some level of ability for those who’ve not previous had that ability. This brings to mind patients with hearing, sight, speech, motor and cognitive impairments. T he scope of coverage for those benefits will have to be weighed against the effect those benefits will have on premiums. Not an easy task. It also appears that what is allowed in the way of essential benefits must also conform to PPACA’s provisions for unlimited benefits under qualified health plans.
Additionally, states may consider services deemed “non-essential” by HHS. These include autism, chiropractic, acupuncture and infertility services. These services may have lifetime and/or annual limits imposed on them but may still drive dramatically premium costs.
Although states seem to be relieved and perhaps pleased by HHS’ announcement that they would be given latitude in implementing the Essential Benefit provisions of PPACA, it does seem that HHS just punted this hot potato issue. The battle of the details now moves to the states and I would guess that that exact nature and scope of “habilitative benefits” and the inclusion of non-essential benefits will be hotly contested in many state houses this year.
Since Washington doesn’t seem to be very good making hard decisions we now must look for more courageous leadership from the states.
JL Sugden
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