One important section of the Affordable Care Act is section 1302, which sets standards for essential benefits. Essential benefits are the benefits that all companies intending to use health insurance exchanges, must provide. While this provision is important to the overall goal of providing access to affordable and quality health care, it is very general, and similar to many other sections in this law. It delegates a lot of authority to the Department of Health and Human Services to define essential benefits, and to make appropriate changes over time.
This means that things are going to be changing. Companies small and large will have numerous compliance issues to follow with this law and others. Compliance will be a moving target, and essential benefits are subject to change over time, requiring companies to assign staff to keep up with developments.
The ten essential benefits include, but are not limited to:
◦ Ambulatory patient services
◦ Emergency services
◦ Maternity and newborn care
◦ Mental health and substance use disorder services, including behavioral health treatment
◦ Prescription drugs
◦ Rehabilitative and habilitative services and devices
◦ Laboratory services
◦ Preventive and wellness services
* Chronic disease management
* Pediatric services, including oral and vision care
The Department of Health and Human Services, along with the Department of Labor, surveyed several employers to determine the most common benefits offered by employers of all sizes. This information will be disseminated and used as a baseline for developing Essential Benefits. The Institute of Medicine also did a study and their recommendations are to be considered as well. Essential benefits will be a combination of these two things, but details are still being written.
Here is where things get complicated. There is also a provision in Section 1304 saying that benefits receiving either an “A” or “B” rating from the U.S. Preventive Services Task Force can be included at the discretion of the Secretary of Health and Human Services. Benefits like smoking cessation and others score high, according to the Task Force, and regulators may opt to add these conditions/drugs to essential benefits packages. The Federal Employees Health Benefit Package is often seen as a benchmark plan by many policy makers, so look for benefits from that package to be included.
The bottom line is that the Secretary of Health and Human Services defines the specific benefits and will update the package periodically to address gaps or to respond to changing medical practices. This means employers who do not self insure will have to monitor these changes. Many anticipate 2016 is a year the business community should watch closely. Stay tuned for coverage on this issue and others.