Health care reform corner: A look at essential health benefits

The basics

Part of the Affordable Care Act is the requirement that small group and individual plans cover essential health benefits. Included are things like screenings for cancer and diabetes, vaccinations and chronic health condition management. A plan’s coverage of essential health benefits is one factor in determining if it is a qualified health plan under the Affordable Care Act.

What are the essential health benefits?

Essential health benefits fall into these categories:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance abuse disorder services, including behavioral health treatment
• Prescription drugs
• Habilitative and rehabilitative services and devices
• Laboratory services
• Preventive and wellness services, and chronic disease management
• Pediatric vision and dental services

What isn’t considered an essential health benefit?

There are several benefits that fall into this category:

• Non-covered procedures per BCBSM’s medical policy
• Voluntary termination of pregnancy
• Gender reassignment surgery
• Radial keratotomy
• Chemical peel for acne
• Private-duty nurse
• Special foods for inherited metabolic diseases of childhood
• Artificial insemination 

Who gets these benefits?

The essential health benefit requirement applies to non-grandfathered individual plan members and small group plan members for 2014. To be sure that BCBSM’s plans are compliant with the Affordable Care Act, we needed to make sure that our new plans in 2014 for individuals and small groups met this requirement.

When will the benefits be available to patients?

The benefits take effect with the plan year effective date. It may or may not be in the first part of 2014. It’s extremely important that you continue to check your patients’ benefits and eligibility on web-DENIS or CAREN.

What about cost-sharing?

In some cases, the benefits are available with no cost-sharing (deductible, copay, coinsurance) requirements. In other cases, there is a cost-sharing requirement that ends once the member reaches the out-of-pocket maximum. Again, it’s extremely important that you check benefits, eligibility and status of cost-sharing on web-DENIS or CAREN.

For more information about health care reform, go to bcbsm.com. For benefits and eligibility questions, check web-DENIS or call CAREN.