Insurers and patients are waiting to find out what types of medical services will be considered “essential benefits” by the Obama administrative and singled out for mandatory coverage.
The Affordable Care Act specifies 10 areas of medical care in which insurers must provide coverage once all Americans are required to have health coverage in 2014. It includes areas already covered widely by insurers, like hospitalization and prescription drugs, and areas that aren’t usually covered in typical plans, like habilitation services and dental care for children.
It’s up to the secretary of Health and Human Services to outline exactly what services within those categories are considered essential.
Until that happens, it’s hard to predict how much insurance companies will be affected by the new mandates, said Paul Fronstin, a director for the Employee Benefit Research Institute. He said the impact will depend on the detail to which HHS outlines the essential services.
“When you look at the 10 different categories, most plans cover out-patient services, in-patient services, prescription drugs,” he said. “But they cover them in different ways.”
Mr. Fronstin sat on the Institutes of Medicine panel charged with recommending to HHS how the agency should define essential benefits and go about updating them each year. The panel recently completed its report, which is expected to be released in September.
The panel’s key task was how to determine whether a medical service is necessary while also taking into consideration the cost of coverage, evidence of its effectiveness and how existing state standards of essential benefits would factor in, he said.
“We had to wrestle with issues of medical necessity, the role of state mandates, the cost of the package, evidence-based medicine,” Mr. Fronstin said. “Those are the kinds of issues we discussed.”
The other categories of coverage outlined in the ACA include: ambulance services, emergency services, maternity care, mental health and substance use treatment, rehabilitative services (coupled with habilitation services), lab services and preventative services and chronic disease management.
HHS also held two workshops earlier this year, in Washington, D.C., and in Costa Mesa, California, where the public could weigh in on defining essential benefits.
On Monday, the agency released a report on the workshops.