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Essential Health Benefits - Obama Passes the Buck

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The Obama Administration took a politically expedient escape from the essential health benefits political minefield - defining which medical benefits insurance companies will have to include in their health insurance offerings in 2014. Referred to as the essential health benefits, this group of benefits would form the minimum health benefit package available both inside the state health insurance exchanges and in the private health insurance market as well.

In California, that gives state leaders - the legislature as well as the California Health Benefit Exchange - more control of health insurance. It remains to be seen whether this is a blessing for Californians. Will the shifting of responsibility to the state ease implementation of the Exchange or burden it further? Will health insurance costs be controlled or spike higher as a result of additional benefit mandates demanded by various consumer groups and special interest groups like hospitals and pharmaceutical companies.

It also puts the Immediate pressure on the Exchange Board. Board members got a quick briefing on the proposed requirements, since comments on them are due at the end of January 2012. That leaves the board with one more meeting — on Jan. 17 — to approve comments on those benefit requirement. The Board was totally unprepared for this development.

The Affordable Care Act (ACA) already includes these benefit categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, pediatric services, including oral and vision care. Some of these benefits, namely habilitative care for autism and pediatric oral and vision care, are not included in typical health insurance plans in most states currently.

States can define their own set of essential benefits by using an existing major health benefit plan in the state as a benchmark. California benchmarks would include one of the three largest federal employee health benefit plans by enrollment, one of the three largest state employee health benefit plans by enrollment, one of the three largest small business plans by enrollment. Many fear these federal and state employee benefit benchmarks set the bar too high, and the largest HMO plan offered in the state’s commercial market by enrollment. These plans are more comprehensive and thus more expensive than most individuals and small businesses can afford.

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