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Update Regarding Essential Health Benefits
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.