Tuesday, December 20, 2011

HHS Blinks On The Affordable Care Act's Essential Health Benefit

Remember that Affordable Care Act (ACA) "essential health benefit (EHB)?" 

While Disease Management Care Blog doesn't want to be reminded about it either, the topic bubbled into the health policy news cycle thanks to this sleeper bulletin recently released by HHS. Recall, despite the ACA requiring an approach based on a "typical" insurance plan covering ten categories of services, that the law set the stage for a requirement that every U.S. health insurer would have to potentially cover an expansive, complicated, expensive and controversial suite of services in each and every health insurance policy.  Any insurance plan not meeting the EHB would be excluded from the exchanges.

While the DMCB feared the unable-to-say-no amateurs in HHS would stumble their way into an unaffordable and one-size-fits-all package, it appears they've blinked.  That's because they've discovered that the ACA misread things: while insurance policies typically cover a core set of services, they vary in coverage of other services.  That includes dental care, acupuncture, bariatirc surgery, hearing aids, tobacco cessation, in-vitro fertilization, certain autism services, a variety of mental health and substance use disorders and habilitative (yes, that was a new one for the DMCB too) services.

How does HHS intend to reconcile this?

"We intend to propose that EHB be defined by a benchmark plan selected by each State."  


In other words, there would be 50 EHBs.  As the DMCB understands it, each would be calculated using an intra-state combination of the largest small group plan, any of the largest thee state employee plans, any of the large three national FEHBP plans and the largest commercial plan.  If a state doesn't calculate the benefit, the Feds intend to use the one used by the largest small group insurance plan.  If the calculation doesn't include sufficient coverage in all the ten categories, the ultimate default is using whatever is in the state's largest FEHBP plan.

Business groups and state leadership will probably find the local state-based approach a more palatable alternative, while some professional (for example) and patient advocacy (for example) may be disappointed.

No comments: