A state can decide for itself how it wants its official “essential health benefits” (EHB) package to handle services for children with developmental disorders.
A state also will have at least two options for deciding how it wants to handle pediatric dental and vision benefits in the EHB package.
The U.S. Department of Health and Human Services (HHS) has confirmed that it will be taking that approach to running the EHB program in an advance version of a new final rule, “Patient Protection and Affordable Care Act; Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation” (CMS-9980-F).
The final rule is set to appear in the Federal Register Feb. 25. The rule will take effect 60 days after the publication date.
PPACA opponents are still trying to repeal PPACA or block implementation of the law, and HHS or other departments could postpone implementation of parts of the law. If the law takes effect on schedule and works as expected, it will create a new system of exchanges, or Web-based health insurance supermarkets, starting Oct. 1.
In an effort to help consumers shop for coverage on an apples-to-apples basis, PPACA will require all non-grandfathered individual or small group insurance plans to cover the EHB package.
The plans will have to cover the EHB package whether the plans are sold through an exchange or outside the exchange system.
The EHB package requirements will not apply to grandfathered plans, self-insured plans or large group plans.
HHS is giving each state some ability to adjust its EHB requirements, by creating a state EHB benchmark based on the list of benefits offered by a popular plan sold in that state. But a state’s EHB benchmark also must meet PPACA guidelines. PPACA requires each EHB package to include 10 classes of benefits.
Consultants at Milliman found that most EHB benchmark candidate plans offer similar benefits, and benefits similar to those required by PPACA, with three major exceptions: pediatric vision benefits, pediatric dental benefits, and “habilitative benefits,” or rehabilitative benefits for children or adults with developmental delays who may need help with acquiring basic life skills.
The sponsors of many benchmark candidate plans have offered pediatric dental and pediatric vision benefits through separate insurance policies, analysts have found.
States, insurers, employers and groups representing parents of children facing developmental delays have spent years fighting emotional battles over whether states should mandate that plans provide coverage for expensive habilitative services, such as applied behavioral analysis (ABA) for people with autism. ABA therapy and similar types of therapy can cost $30,000 a year or more.
In an EHB bulletin issued in December 2011, and in documents released in January 2012, February 2012 and July 2012, HHS suggested that it would let states decide to handle habilitative services for themselves.
HHS has proposed letting states handle gaps in a proposed benchmark plan’s pediatric and vision benefits by adopting either the benefits that federal employees who pay for dental and vision coverage get, or the dental and vision benefits that the state’s Children’s Health Insurance Plan program provides.
HHS received about 11,000 comments on the proposals.
Many commenters asked HHS to use a state’s Medicaid plan as the benchmark for habilitation, pediatric dental and pediatric vision benefits.
“In order to maintain the states’ role in defining required benefits in their markets, we will finalize the regulations to provide for state flexibility in determining how to define habilitation services and to offer other options for supplementing based-benchmark plans that do not include coverage for pediatric dental and vision services,” officials said.
If the EHB benchmark plan a state chooses does not cover habilitative services, the state can use the Medicaid definition of habilitative services or the National Association of Insurance Commissioners definition.
If a state chooses not to define habilitative benefits, the issuers can choose how to define the term, officials said.