California works toward finalized essential health benefits

July 03, 2013

Two California agencies are working through the final steps of ensuring that all health insurers provide coverage for 10 broad categories of coverage that are required under the Affordable Care Act (ACA).

Under the ACA, all plans offered through state exchanges are required to meet these 10 categories of coverage, and now, state regulators are filling in final details to ensure that all plans in the individual and small group markets will be offering generally the same set of benefits.

This benefit package, known as essential health benefits (EHB) has been covered at length in previous issues of CMA Reform Essentials, and the federal rules further defining them were finalized earlier this year. While the federal government handed down the 10 categories of benefits that state exchange plans must cover, the final rule did not specify any patient cost-sharing or coverage limits (e.g., visit limits) tied to the benefits.

Through emergency regulations put forward by the Department of Insurance and the Department of Managed Health Care, all health insurers in California will be required to cover the following broad areas:

  • Ambulatory patient services

  • Emergency services

  • Maternity and newborn care

  • Prescription drugs

  • Hospitalization

  • Laboratory services

  • Pediatric services, including oral and vision care

  • Rehabilitative and habilitative services and devices

  • Preventive and wellness services and chronic disease management

  • Mental health and substance use disorder services, including behavioral health treatment

At its June meeting, the Covered California board, made offering pediatric dental benefits optional for health plans in the exchange in response to recently proposed federal regulations. Pediatric dental benefits, which will be offered through stand-alone plans on the exchange, were not included in the qualified health plan (QHP) solicitation process and requiring such benefits of exchange plans could have caused major delays in the launching of California’s exchange.

The aforementioned emergency regulations also drew some negative attention from stakeholders for the degree to which they specify covered treatments, stating that such specificity could cause issues for patients if the standard of care shifts away from such treatments. Services and supplies specified in the regulations include:

  • Acupuncture services to treat nausea or chronic pain;

  • Nonemergency ambulance and psychiatric transport services;

  • Chemical dependency services, including inpatient detoxification, outpatient evaluation and treatment, and transitional residential recovery services;

  • Special contact lenses to treat aniridia or aphakia;

  • Durable medical equipment for home use, including canes, crutches, pressure pads, IV poles, enteral pumps, bone stimulators, phototherapy blankets and dialysis care equipment;

  • Organ donation services;

  • Mental health services for those with non-severe mental disorders on both an outpatient and inpatient basis;

  • Ostomy and urological supplies;

  • Prosthetic and orthotic services and devices; and

  • Procedures for the prenatal diagnosis of fetal genetic disorders.

For prescription drug benefits, exchange plans must cover the same number of drugs in each category and class as the state’s chosen EHB benchmark plan, the Kaiser Small Group HMO.

We anticipate final exchange plan explanations of benefits (EOB) being made publicly available through www.CoveredCA.com within the next two months. Stay tuned for more details.


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