Essential health benefits: Reactions to the final rule


After the U.S. Department of Health & Human Services released its final rule detailing which benefits insurers must provide in 2014, industry stakeholders had varying reactions.

America's Health Insurance Plans applauded the agency's flexible approach to the standard benefits design and its decision to defer to states' benchmark plan selections, but called out the rule's potential impact on cost. "As the reform law is fully implemented, it will be important to keep in mind how the EHB requirement interacts with other provisions in the law that will add to the cost of health care coverage, such as the new health insurance tax and restrictions on age rating," AHIP CEO Karen Ignani said in a statement.

One of the main changes from the proposed rule--requiring insurers provide mental health and substance abuse coverage--also garnered a lot of reaction. "We are a giant step closer to all people--particularly people with chronic health conditions--having access to meaningful coverage," Marc Boutin, executive vice president at the National Health Council, told The Wall Street Journal.

Meanwhile, the American Cancer Society Cancer Action Network was pleased that HHS is prohibiting insurers from charging a co-payment if a polyp is removed during a colonoscopy. Although colonoscopies are considered preventive care, some insurers were classifying a polyp removal during the procedure as "diagnostic," and therefore, charging patients for all or part of the costs. "We specifically went to HHS with this issue a few months ago," Senior Director of Policy Stephen Finan told USA Today.

But not everyone supported the final rule. Carl Schmid, deputy executive director of the AIDS Institute, was disappointed that HHS didn't spell out explicit, uniform national standards that include a broad range of drugs, The New York Times reported.

"We thought the federal government would spell out essential health benefits in more detail," he said, explaining that the patients will now have different access to drugs depending on which state they live in. "Under this rule, patients might have access to a total of 500 drugs in one state and more than 1,000 in another state," he added.

To learn more:
- read the AHIP statement
- see the Wall Street Journal article
- check out the USA Today article
- read the New York Times article

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