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Update Regarding Essential Health Benefits

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The Patient Protection and Affordable Care Act (or health care reform law) includes key provisions that eliminate lifetime dollar limits and restrict annual dollar limits for essential health benefits. This provision is effective for plans upon renewal beginning on or after September 23, 2010 and applies to medical and pharmacy benefits only. Certain limited benefit plans may continue to include annual dollar limits if they are eligible for a waiver program, as defined by the U.S. Department of Health and Human Services (HHS). Providers should continue to verify eligibility and benefits to confirm how health care reform provisions impact specific members.  
 
Under the health care reform law, the secretary of the U.S. Department of Health and Human Services (HHS) is responsible for defining which services are considered essential health benefits. Regulations to fully define essential health benefits have not yet been issued, and good faith compliance is required until we receive detailed regulations from HHS about essential health benefits. For 2010 implementation, we made decisions based on examples released by HHS, as well as our own research of current state and federal mandates.  
 
The following list includes services we believe may be defined as essential health benefits and therefore we will remove existing dollar limits on these benefits upon plan renewals on or after September 23, 2010. Please note that this list applies in general, and that benefits may vary based on state mandates or requirements. Listed services still may be subject to copays and other out of pocket costs.  
 
Allergy injections and/or testing
Ambulance
Ambulatory surgical services
Asthma education
Bariatric surgery
Cardiac rehab
Chiropractic manipulation services and/or osteopathic manipulation
Diabetic supplies and glucometers
Diagnostic services
Dialysis and kidney disease treatment
Durable medical equipment, medical equipment and supplies, oxygen
Emergency room services
Enteral formula and modified low protein food products
Hearing aid
Home health care
Hospice
Infusion therapy, home infusion therapy
Inpatient or outpatient facility services
Inpatient rehab/physical therapy
Maternity
Mental health/substance abuse inpatient and/or outpatient
Office visits
Ostomy supplies
Outpatient occupational therapy
Outpatient physical therapy
Outpatient speech therapy
Pharmacy and prescription drugs/injections
Preventive care and preventive screenings
Prosthetic devices or limbs
Pulmonary or respiratory rehab/therapy
Skilled nursing
Surgical and anesthesia services
Transplant services
Treatment of TMJ
 
Once we receive further definition from HHS about essential health benefits, we may adjust this list based on the definition provided by HHS. We will continue to update you as changes occur.  
 
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