What’s an Essential Health Care Benefits?

A whole bunch of new rules and regulations are set to kick in 2014 under the Affordable Care Act (better known as ObamaCare). One of the most nettlesome for those in the health insurance industry – and of great importance to you if you purchase small group health insurance or individual health insurance – is defining “essential health care benefits.”

In an attempt to provide a definition, the Affordable Care Act states that essential health care benefits must include at least the following general categories and the items and services covered within the categories:

  • ambulatory patient services
  • emergency services
  • hospitalization
  • 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 and chronic disease management
  • pediatric services, including oral and vision care

But Congress left the details of the items and services and the precise contents of the prescribed ObamaCare essential health care benefits package up to Health and Human Services Secretary Kathleen Sebelius.

Among the many problems HHS faces in detailing what goes in a typical group plan is the avoidance of micromanagement that interferes with the ability of health insurance companies to offer consumers choices or squashes insurers’ ability to incentivize consumer-driven cost controls. At the same time, the language defining the specific services required in each of the 10 essential health care benefits needs to be sufficiently precise to prevent insurance companies from putting restrictions on their use and thereby denying you treatment vital to your health. In simple terms, can your health care plan promise you a discount if you forego costly MRIs? Or refuse to give you a second coronary bypass? Nobody’s sure.

Some other thorny issues that will heat up the essential health care benefits package debate include:

  • How much weight to give to the existing minimum benefits each state currently requires
  • Whether non-emergency care administered in an Emergency Room will be covered as an emergency service
  • Which conditions and treatments qualify for habilitative care (which helps people acquire skills they never had as opposed to rehabilitation which restores lost skills)
  • Whether fertility treatments like in vitro fertilization are be included in essential maternity and new born care
  • Whether lifestyle drugs such as Cialis™ or Viagra™ are covered under prescription drugs
  • Whether orthodontics are covered in the pediatric services oral care provision

In an attempt to work it out, Sebelius has requested recommendations from the Institute of Medicine (IOM), which is according to its website, “an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public.” Until the jury is in, you still have the option to shop for small group health insurance quotes or individual health insurance quotes, and find competitively priced plans that meet your essential needs. If you want health insurance quotes to compare or health insurance information, go to EINSURANCE.com.


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