Organ Transplants .... Essential v. Nonessential Benefit

[Guest ERISAQUEEN]

I am wondering if there has been discussion on how organ transplants will be viewed under the annual limits requirements of the Patient Protection and Affordable Care Act. Specifically, will organ transplants be considered an essential or a nonessential benefit? Any thoughts or discussion on this is appreciated.

[mdm09]

There has been no guidance on essential health benefits. Until HHS issues regulations there is no way to know for sure which benefits will be considered “essential” within those broad categories set forth under the statute. For purposes of enforcement, until regulations are issued the agencies will take into account “good faith” efforts to comply with a reasonable interpretation of essential health benefits, but a plan must apply its definition consistently. (This last line is from the preamble to the "Patient's Bill of Rights" interim final reguations published in the Fed. Reg. on June 28, 2010.)

That said, the statute does include such broad categories as ambulatory patient services and hospitalization.