Essential Health Benefits Rule Issued
|by Kelly Kennedy, USA TODAY|
The rule defines what must be covered in exchange plans, prohibits discrimination based on age or pre-existing conditions, describes prescription drug benefits and determines levels of coverage.
"The Affordable Care Act helps people get the health insurance they need," said HHS Secretary
The states and insurers had been particularly interested in what kind of mental health and substance abuse coverage they would have to include. The new rule provides parity for both, and HHS released a report today that showed that could affect 62 million people.
But the rule doesn't include any surprises: A proposed rule released in November looks much the same as today's version.
Some groups, such as the American Cancer Society Cancer Action Network, praised the section that said insurers may not charge a co-payment if a polyp is removed during a colonoscopy. That's good news for patients who have a preventive exam and wake up to learn they had a procedure they must pay for, said spokesman
The essential health benefits include ambulatory patient services; emergency care; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and rehabilitative services and devices; laboratory services; preventive and wellness services, and chronic disease management; and pediatric services, including dental and vision care.
Plans in the individual and small-group markets inside and outside of health care exchanges must cover essential health benefits beginning in 2014.
Health care exchanges, or marketplaces, allow consumers to go to a website and compare benefits and costs of different plans. HHS's essential rules are meant to make the categories comparable, though states may require more from the insurers that participate in the exchanges.
The rule also assigns "metal" ratings to different levels of plans, so a consumer will know that a bronze plan will have less generous benefits, but will cost less than a platinum plan.
Much of what will be included is similar to what is commonly covered by plans now, but there will be some changes in the small-group market, including coverage of mental health issues and substance abuse disorders, habilitative care, pediatric dental care and pediatric vision care.
But HHS also predicted in the rule that many individual market plans will not cover all 10 essential health benefits, which should help keep costs down.
The rule also states an insurer may not discriminate based on an "individual's age, expected length of life, present or predicted disability, degree of medical dependency, quality of life or other health conditions."
HHS received about 11,000 comments before posting the final rule, including health insurance issuers, consumers, health providers, states, employers, employees and
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