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Researchers track essential health benefits efforts

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Meeting the new federal health benefits package standards for habilitative services may be complicated and confusing, but a need to add children’s dental and children’s vision care standards has been more common.

Sabrina Corlette and other Georgetown University health policy researchers have published that finding in a report distributed by the Urban Institute.

The researchers wrote the report to show how five states — Alabama, Colorado, New Mexico, Oregon and Virginia — are responding to the Patient Protection and Affordable Care Act “essential health benefits” package requirements.

The PPACA EHB provisions call for all nongrandfathered individual and small-group plans, inside and outside the public exchange system, to offer a standardized package of benefits starting Jan. 1.

The EHB benefits list includes some benefits that most individual and small-group major medical plans already offer, including coverage for outpatient care, emergency services, hospital care, laboratory services, and preventive care services.

The benefits package also includes benefits left out of some low-priced individual policies but usually included in small-group policies: Coverage for prescription drugs, maternity and newborn care, and mental health services.

In most states, those EHB requirements have had little effect on the commercial health insurance market, the researchers said.

In one state, Virginia, regulators did report a major market change, but they also reported seeing a significant expansion of benefits for individual policyholders, researchers said.

All but one of the five states studied had to add both pediatric dental and vision benefits to meet the EHB standard.

Only three of the states had to add standards for habilitative services — rehabilitation-like services provided for individuals born without certain abilities, such as the ability to walk or the ability to talk. 

But PPACA and federal regulators did not set a definition for habilitative services, and some states have not come up with definitions, either, the researchers said.

“Some of our insurer respondents indicated they would just ‘copy what we have on the physical therapy side’ to comply with the requirement to cover habilitative services,” the researchers said.

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