Infertility treatments, massage care ‘essential’ in some states

Minimum coverage is a mixed bag

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Health insurance plans being set up in Kansas under President Obama’s health care law will have to cover infertility treatments, but those in Arkansas and Colorado won’t.

Maryland plans must cover weight-loss surgery, while those in Michigan have to pay for chiropractic care. Oregon plans won’t be forced to cover either of those – officials there say that covering such procedures would make premiums too expensive for most residents.

Twenty-two states and the District of Columbia have laid out what they consider to be the minimum coverage that must be made available to those obtaining insurance through small employers or the new state-based exchanges under the federal health care law.

Those states are grappling with the edges of medical care, debating whether infertility treatments, visits to chiropractors and time with massage therapists are considered “essential” in 21st-century medicine.

The law called for states to set rules for health care plans offered by small employers and plans offered under the state health care exchanges, where those without insurance will be able to shop for plans. The rules don’t apply to companies with 50 or more employees because those plans tend to already include a large range of benefits.

Called “essential health benefits” by the 2010 health care law, the mandatory coverage falls into 10 categories ranging from emergency services – which are covered by most insurers – to “habilitative services,” which are less commonly covered.

Some of the decisions were easy. Most states already have laws requiring coverage for diabetes or mental health care, for example. Some states included services that go above and beyond what is required by federal law – such as Washington, whose plan will cover massage therapists and doctors who specialize in natural remedies.

But states ran into trouble figuring out how to include some services that the federal law requires but have not traditionally been part of standard coverage. Among those is dental care for children, which is one of the essential health care benefits the plans must cover.

Because insurers typically offer separate dental plans, pediatric dental coverage wasn’t included in most of the benchmark plans the states selected. To solve the problem, most states tacked on supplemental dental plans, said Sonya Schwartz, director of the National Academy for State Health Policy.

“That’s one area where states had to spend a little extra time figuring out what to do,” Ms. Schwartz said.

Many of the states left a big question mark under the category of habilitative services – a broad category that is tough to define, though it usually includes trying to help those with disabilities learn language, physical skills or social skills.

“It was like, well, we don’t even know what those are,” said Linda Shepherd, who is overseeing implementation of the health care law for the Kansas Insurance Commission. “That was just an area that is sort of hanging out there.”

So Kansas and other states put the problem on hold, declining to issue any recommendations and hoping they eventually will receive more specific guidance from the administration.

As the clock ticks down to January 2014, when the plans must be ready for sale, some states are objecting to the entire exercise of setting benchmarks, saying they need more information from the federal government.

Alabama Gov. Robert Bentley, a staunch opponent of the health care law, announced Monday that his state won’t select essential health care benefits, saying it would be irresponsible without more guidance from the Department of Health and Human Services.

“As both a physician and a governor, I have determined that it is irresponsible and shortsighted to make a decision on essential health benefits by confining the decision to a select few plans and without having been offered clear guidance from the federal government,” Mr. Bentley wrote in a letter to HHS Secretary Kathleen Sebelius.

Seventeen states – many led by Republicans who want the health care law repealed – have taken no public action toward selecting benchmark plans, according to health care advisory firm Avalere Health LLC. Other states that have taken action, such as Virginia, still refuse to declare their plans to the administration at this point.

“Until such time as the rules are properly issued, states, including Virginia, should not be forced into declaring their selection of an essential health benefits package,” Virginia Gov. Bob McDonnell wrote to the administration last month.

States were allowed to choose a benchmark plan from among the three largest small-group, state employee or federal employee plans, or use the largest health maintenance organization plan offered in the state’s commercial market. The majority of them chose small-group plans because they typically meet existing state coverage laws.

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