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Essential Benefits under Health Reform

What are Essential Benefits?
Under the Affordable Care Act (ACA), most health insurance plans (including plans offered in state Health Insurance Marketplaces) 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.

For individuals with disabilities, the inclusion of rehabilitation and habilitation services in the initial list of Essential Health Benefits was 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:
Under the ACA, the Department of Health and Human Services (HHS) was given the authority to further define the specifics of Essential Health Benefits, while remaining consistent with these required elements. However, HHS instead proposed to define Essential Health Benefits using what is known as a "benchmark approach." Under this approach, each state was given 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 outlined the Department's proposed policies to guide states in defining Essential Health Benefits. Under its intended approach, an existing plan selected by States as a "benchmark plan" would be required to include all 10 categories defined in the Affordable Care Act. If the selected benchmark plan did not initially cover a category, it must be supplemented.

In January 2013, HHS released a proposed rule outlining how states and insurers could define standards related to coverage of Essential Health Benefits and actuarial value. Most notable for people living with disabilities, the regulation provided states with more flexibility to coordinate Medicaid eligibility, and also addressed habilitative services that must be included in Essential Health Benefits. The regulation permitted states to define habilitative benefits using a "transitional approach," in which states define the benefits themselves or allow health insurers to do so.

Next Steps?
The Reeve Foundation strongly supports many important provisions of the Affordable Care Act 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.

As HHS and states continue to define Essential Health Benefits, the Reeve Foundation will 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.

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Continue Christopher Reeve's LegacyPhoto by Timothy Greenfield-Sanders