Essential Health Benefits

[KimberlyC]

I recognize there is no official guidance yet from HHS on what constitutes "essential health benefits" under PPACA, but I am trying to discover what employers are doing/attorneys are counseling in the interim. Several of my clients limit chiropractic visits to a specified annual dollar amount (e.g., $1,000). The annual limits on essential health benefits need to be removed (or phased out for grandfathered plans) this year. Is it reasonable good faith to retain the annual limit until there is guidance deciding whether chiropractic services are essential health benefits? if the plan sponsor removes the dollar limit and either imposes an annual limit on chiropractic visits or requires preauthorization of chiropractic services after the 5th visit will this adversely impact the health plan's grandfathered status? These clients are self-insured and aren't bound by insurance company decisions (which appear to be going both ways on the chiropractic services/essential health benefit issue).

[J Simmons]

I recognize there is no official guidance yet from HHS on what constitutes "essential health benefits" under PPACA, but I am trying to discover what employers are doing/attorneys are counseling in the interim. Several of my clients limit chiropractic visits to a specified annual dollar amount (e.g., $1,000). The annual limits on essential health benefits need to be removed (or phased out for grandfathered plans) this year. Is it reasonable good faith to retain the annual limit until there is guidance deciding whether chiropractic services are essential health benefits? if the plan sponsor removes the dollar limit and either imposes an annual limit on chiropractic visits or requires preauthorization of chiropractic services after the 5th visit will this adversely impact the health plan's grandfathered status? These clients are self-insured and aren't bound by insurance company decisions (which appear to be going both ways on the chiropractic services/essential health benefit issue).

My friend, a chiropractor, is certain that his services are 'essential health benefits'. I think with the insurance industry going both ways on the issue until regulations are issued, it is probably reasonable and in good faith to consider chiropractic not 'essential health benefits'--at least as long as the insurance industry is not lopsided towards including such benefits.

Keep in mind, HHS is under no obligation to give a reasonable good faith pass, and may not do so if it is perceived to result in too much erosion against the purposes of the 2010 Health Care Reform. So the real question is whether imposing this limit would be worth risking the loss of grandfathered status, given the uncertainty. Most employers that I advise are clinging to grandfathered status for dear life. I don't think they'd take the risk, just for the relatively minor benefit that would come with capping or requiring pre-authorization of chiropractic benefits.

[KimberlyC]

I recognize there is no official guidance yet from HHS on what constitutes "essential health benefits" under PPACA, but I am trying to discover what employers are doing/attorneys are counseling in the interim. Several of my clients limit chiropractic visits to a specified annual dollar amount (e.g., $1,000). The annual limits on essential health benefits need to be removed (or phased out for grandfathered plans) this year. Is it reasonable good faith to retain the annual limit until there is guidance deciding whether chiropractic services are essential health benefits? if the plan sponsor removes the dollar limit and either imposes an annual limit on chiropractic visits or requires preauthorization of chiropractic services after the 5th visit will this adversely impact the health plan's grandfathered status? These clients are self-insured and aren't bound by insurance company decisions (which appear to be going both ways on the chiropractic services/essential health benefit issue).

My friend, a chiropractor, is certain that his services are 'essential health benefits'. I think with the insurance industry going both ways on the issue until regulations are issued, it is probably reasonable and in good faith to consider chiropractic not 'essential health benefits'--at least as long as the insurance industry is not lopsided towards including such benefits.

Keep in mind, HHS is under no obligation to give a reasonable good faith pass, and may not do so if it is perceived to result in too much erosion against the purposes of the 2010 Health Care Reform. So the real question is whether imposing this limit would be worth risking the loss of grandfathered status, given the uncertainty. Most employers that I advise are clinging to grandfathered status for dear life. I don't think they'd take the risk, just for the relatively minor benefit that would come with capping or requiring pre-authorization of chiropractic benefits.

Thank you for your thoughts on this. I know the various chiropractor groups are lobbying hard on this one, as are other special interest groups. If the standards just applied to employers i expect that HHS would deem most services to be "essential," but the essential health services definition is a major component of the health plan packages to be offered to individuals and small businesses on the health insurance exchanges as well; if the definition is too broad the exchange plans won't be affordable.... so HHS may not be as inclusive when it ultimately issues guidance.

I agree that it may not be worth risking grandfathered status over a dollar cap on chiropractic services. Of course, if an employer eliminates a cap they probably can't add it back later when guidance comes out or risk losing grandfathered status....

[Guest Little Archer]

Essential health benefits must include follwing items and services:

Ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health; prescription drugs; rehabilitative and habilitative services and devices; and laboratory services etc.