State Medicaid plan managers can tinker with autism therapy and infertility treatment benefits but must meet federal mental health parity standards.
Officials at the Centers for Medicare & Medicaid Services (CMS) have given those instructions in a new batch of Patient Protection and Affordable Care (PPACA) regulations, “Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment” (CMS-2334-F).
Parents and providers have waged big, successful political battles for rich autism therapy benefits mandates in many states, and CMS seems to be responsibility for continuing or ending that fight in the hands of state officials.
Elsewhere in the regulations, CMS officials set guidelines for states that want to keep employers with health plans from trying to shift workers’ children into state Children’s Health Insurance Program (CHIP) plans.
Officials also are brushing off commenters who asked CMS to keep health insurance agents and brokers from helping children and low-income people sign up for state Medicaid or CHIP coverage.
CMS, an arm of the U.S. Department of Health and Human Services (HHS), is getting ready to publish the 606-page final rule in the Federal Register July 15.
The regulations are set to take effect 60 days after the official publication date.
PPACA, the EHB package and ABA therapy
PPACA opponents are still fighting to block or delay implementation of all or part of PPACA, and the Obama administration recently delayed enforcement of a PPACA provision that could require many employers to provide health coverage or else pay a tax.
If the law takes effect as written and works as drafters expect, it will require HHS to work with state agencies to set up a new system of health insurance exchanges, or Web-based insurance supermarkets, by Oct. 1.
The exchanges are supposed to help eligible individuals sign up for public health programs, such as Medicaid plans and CHIP programs, as well as to help other individuals sign up for commercial health plans, or “qualified health plans” (QHPs), sold through the exchanges.
Other PPACA sections will require the QHPs sold through the exchanges to cover a standardized package of 10 types of “essential health benefits” (EHB).
States and their exchanges have some flexibility to design their own QHP EHB packages, but each state is supposed to use the benefits package of a widely used government health plan or a widely used small-group plan to serve as a “benchmark,” or model, for its EHB package.
Even if the benchmark plan does not provide dental and vision health benefits for children, a state’s EHB package must include children’s dental and vision benefits.
Similarly, if benchmark plan coverage for “habilitative services” — rehabilitation-type services for people born without certain abilities, such as the ability to talk or walk — is much different from the plan’s coverage for rehabilitation services, then a state either must come up with EHB habilitative services requirements or default to a requirement that EHB habilitative benefits must be comparable to rehabilitative benefits.
The PPACA EHB habilitative services provision could apply to users and providers of many different types of therapy, such as ordinary speech therapy for children who have trouble talking, or ordinary occupational therapy for children who have participating in class, but, in practice, the most active habilitative benefits battles have been over benefits for children with autism and related disorders.
Many parents of children with autism seek coverage for applied benefits analysis (ABA) therapy and other forms of intensive therapy that can cost more than $30,000 per year. The parents and their supporters contend that the money spent on the therapy can help some children who might end up spending their lives in institutions gain the ability to live on their own, work in the community and pay taxes.
The new final rule applies only to standards for “alternative benefit plans” — state-run Medicaid plans and CHIP programs.
The typical plan enrollees are low-income adults and children in low-income or moderate-income families. In some cases, states may open Medicaid and CHIP programs to other groups of people, such as people with disabilities, or people with health problems that have kept them from qualifying for conventional, medically underwritten health coverage.
Private health insurers help run the Medicaid and CHIP programs in most states.
CMS officials have based the final rule on parts of a draft regulation released in January. Consumers, insurance groups, provider groups, employer groups, patient groups and others submitted 741 comments.