Essential Health Benefits Include . . .


Health reform has many employers stretched to try to meet all of the requirements applicable for the first plan year beginning on or after Sept. 23, 2010. One of the many difficulties faced by employers is determining what constitutes an essential health benefit on which there can be no annual or lifetime dollar limits on the value of benefits. There is no definition of what constitutes an essential health benefit beyond the following list of categories of benefits:

1. ambulatory patient services
2. emergency services (which is defined in the interim final regulations under section 2719A of the Public Health Service Act)
3. hospitalization,
4. maternity and newborn care,
5. mental health and substance use disorder services, including behavioral health treatment,
6. prescription drugs (this was an easy concept until the PPACA changes to flexible spending accounts, but now is this just drugs that cannot be obtained without a prescription from a doctor or does it include the "prescribed over the counter drugs and medicines"),
7. rehabilitative and habilitative services and devices,
8. laboratory services,
9. preventive and wellness services and chronic disease management (while preventive and wellness services have some definition after the interim final regulations under section 2713 of the Public Health Service Act, the scope of chronic disease management is a mystery, does it include asthma and allergy, cardiovascular issues, diabetes, or what chronic diseases qualify),
10. pediatric services, including oral and vision care (it is unclear what constitutes "oral and vision care", does it include a mandatory full vision and dental plan coverage, must it be provided to all dependents or only those who are truly considered pediatric patients to age 18).

The absence of guidance on what constitutes "essential health benefits" has left employers guessing and at the mercy of the service providers who are making calls regarding what they believe to be essential health benefits based upon their own opinion. The interim final regulations provide some relief in the preamble for employers making good faith efforts to comply with reasonable interpretations of "essential health benefits" until guidance is issued, but it requires the plan to apply the definition of essential health benefits consistently and this may be difficult for an employer sponsored plan to do when it has more than one vendor with each vendor imposing its own interpretation of what constitutes essential health benefits.

Hopefully, relief will be granted for employer sponsored plans with multiple vendors imposing their own definitions of essential health benefits by considering the application of the same definition by a vendor on its book of business will satisfy good faith compliance for the employer when it may not be able to negotiate with multiple vendors to bring all of their varying definitions into a consistent set of rules for that employer's plans.