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Essential Health Benefits

By Dr. Nilesh Kalyanaraman

As part of the Affordable Care Act, the secretary of Health and Human Services (HHS) was given the task of defining the essential health benefits (EHB) that all health insurance plans in every state must include. The EHBs are a set of services in the following ten categories that each insurance plan, at a minimum, would have to include:

1.     Ambulatory patient services

2.     Emergency services

3.     Hospitalization

4.     Maternity and newborn care

5.     Mental health and substance use disorder services including behavioral health treatment

6.     Prescription drugs

7.     Rehabilitative and habilitative services and devices

8.     Laboratory services

9.     Preventive and wellness services and chronic disease management

10. Pediatric services including oral and vision care

Given the opportunity to define the EHBs and set a standard for the nation HHS showed a lack of resolve and decided to do nothing. More accurately, they decided to let each state define their own EHB. This is a lost opportunity for a number of reasons.

First, the minimum benefits offered from state to state shouldn’t vary. There is no good policy reason to think that someone in Colorado would need a different set of baseline benefits than someone in Georgia. States that are less interested in ensuring the health of their citizens do a great disservice to them and HHS had the ability to help these citizens but chose not to do so.

Without a national standard for EHBs it will be difficult to get to a point where health insurance could be offered across state lines. Presently, there is a law that prevents an insurance product from being sold across state lines. There has been a lot of discussion about eliminating this restriction but the major sticking point is figuring out which state’s standards to apply if a health insurance plan is sold in two states. A national EHB would have gone a long way towards solving this problem by eliminating state to state variation.

The one glimmer of hope is that this is a preliminary report. HHS is still open to comments regarding this plan and you can still make your voice heard by letting them know what you think of this plan. So send an email to HHS by January 31 letting them know your thoughts. We’ve made our voices heard before and we can do it again.

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