Virginia looking to expand Obamacare benefits

Virginia's version of the essential benefits covered by Obamacare individual and small group health insurance would expand under two proposals by the State Corporation Commission.

One measure expands coverage for prosthetic devices, such as artificial limbs, when they are controlled by microprocessors, electric signals generated by a person's muscles or biomechanical methods.

The other would add coverage of special oral and enteral medical formulas for people with an inherited metabolic disorders, even when those formulas are not considered a primary source of nutrition supplying more than 51% of calories needed. That 51% test is the current standard.

The SCC had estimated the cost of expanded access to the formulas at 11 cents a month for each covered person in a health plan, while the consulting actuary hired by the commission calculated the benefit to people enrolled in health plans at 14 cents per person per month.

For access to the costlier prosthetics, the SCC had estimated a cost of 18 cents per person per month while the actuary calculated the benefit as 23 cents per person per month.

The state needs to ask for approval for any changes to its essential health benefits from the federal Centers for Medicare & Medicaid Services, with the application due by May 3.

If approved, the changes would take effect in 2025.

The current essential benefits list covers 54 services, from hospital stays to doctors' office visits to transplants to dental care for children. It does not pick up some options that some insurers may offer, such as weight loss programs, hearing aids, or routine dental care and eye exams for adults.

The essential benefits are required for what are called fully insured plans -- that is, plans insurers sell to individuals or small groups.

Many employers' plans, however, are self-insured and so are not subject to most of the essential benefit requirements, although typically, these plans offer more generous benefits.

The most generous employer plan in Virginia, for federal employees, provides benefits worth $3.04 per covered person per month more than the proposed expansion of Virginia's essential benefits would, according to the actuary's analysis.

Under the Affordable Care Act - Obamacare - health insurers' plans must cover emergency services, hospital care, outpatient care, maternity and newborn care, mental health and substance abuse treatment, prescription drugs, rehabilitation services, laboratory fees, preventive and chronic disease care and pediatric care.