Affordable Care Act implementation guidelines should let insurers and health plans impose sensible limits on use of medical services.
Commenters representing insurers, insurance producers and health plans have made that argument in comment letters now posted on the website of the Employee Benefits Security Administration (EBSA).
EBSA, an arm of the U.S. Labor Department, has posted a batch of 145 comments that it received after it released Affordable Care Act interim final regulations in June.
The Affordable Care Act is the legislative package that includes the Patient Protection and Affordable Care Act (PPACA).
The June regulations, issued by the U.S. Treasury Department and the U.S. Department of Health and Human Services as well as the Labor Department, covered topics such as the rules governing annual and lifetime benefits limits, rescissions, internal appeals, external appeals, provider access, and a ban on consideration of pre-existing conditions when plans or insurers are looking at applications under age 19.
The annual and lifetime benefits limits rules apply only to “essential benefits”; plans still can set separate benefits limits for “non-essential benefits.”
Many of the commenters representing patients with specific conditions have asked officials to ensure that the official definition of “essential benefits” includes the benefits that the people with those conditions need.
Christine Brown, executive director of the National PKU Alliance, Tomahawk, Wis., has asked that coverage for medical foods designed for people with severe metabolic disorders be treated as an essential benefit.
Peter Bell of Autism Speaks, Washington, says the definition of essential health benefits ought to include applied behavior analysis for people with autism and other disorders that affect behavior.
Other commenters have asked federal agencies to use commonsense when essential benefits rules intersect with new Affordable Care Act preventive services coverage requirements.
“For example,” says Ken Crerar, president of the Council of Insurance Agents & Brokers, Washington, “questions have been raised about annual physical exams, which may be classified under the ‘preventive and wellness services’ category of essential benefits and thus subject to no annual or lifetime limits, but which also fall under the preventive services rule and would be subject to first-dollar coverage by non-grandfathered plans.”