Essential Benefits under Health Reform

What are Essential Benefits?
Under the new health care law, most health insurance plans (including new plans to be offered in the state health insurance exchanges) are required to cover at least the following essential benefits: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services (including behavioral health treatment), prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services including oral and vision care.

The Department of Health and Human Services (HHS) has the authority to further define the specifics of essential benefits, while remaining consistent with these required elements. Furthermore, if HHS decides to add essential benefits, the law requires that the health care needs of people with disabilities and other diverse groups are taken into account.

For individuals with disabilities, the inclusion of rehabilitation and habilitation services in the initial list of essential benefits is a step in the right direction. Many people with disabilities rely on such services and, prior to health reform, many insurance policies did not cover them or severely limited the number of treatments allowed.

Recent Action:
The Department of Health and Human Services (HHS) is proposing to define essential health benefits using what is known as a benchmark approach. Under this approach, each state will have flexibility to select a benchmark plan, from a list of 10 designated plans, to serve as the state's standard for essential health benefits.

On December 16, 2011, HHS issued a bulletin that outlines the Department's proposed policies to guide states in defining essential health benefits. The bulletin was released in advance of a more formal rule, which will be released later this spring.

Next Steps?
The Reeve Foundation strongly supports many important provisions of the Affordable Care Act (ACA) that bring the country one step closer to ensuring that all Americans, including people living with spinal cord injury and paralysis, have access to high quality, comprehensive, affordable health care that meets their individual needs and enables them to be healthy, functional, and live as independently as possible.

The Foundation greatly appreciates the law's recognition of essential benefit categories that improve the ability of people living with disabilities and chronic conditions to maintain and improve their functional ability. However, the success of designing the essential health benefits (EHB) package with the level of flexibility prescribed in the December 16, 2012 HHS Bulletin requires substantial consumer protections that will result in a true benefits package – one that will safeguard people as they navigate and enroll in qualified health plans that meet their health care needs.

As HHS moves forward with the process of defining essential benefits, the Reeve Foundation will continue to work with HHS and with partners in the disability community to ensure that the unique health care needs of people living with spinal cord injury and paralysis are taken into account.