Essential Health Benefits

Within its 2,400 pages, the Affordable Care Act did not create any sort of health plan; it left the details and specifics of those to the states. It was not silent on the general rules of healthcare, however, creating a list of ten criteria that it deemed “essential” to insurance coverage. Using this list as an outline, each state* is charged with creating a “benchmark plan”, a representative plan that would serve as a guide for all individual and small group plans.

(And by “create”, I really just mean “choose among several options already available in the state, federal, and small group markets”.)

List of Essential Health Benefits:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

As you can see, this list is very general, and most of the benefits will be open to a wide interpretation. Regardless, this helps to standardize coverage in an important way: The benchmark plan that each states comes up with must address all ten EHB, and this plan will be used as a point of reference (or, benchmark) for private insurance policies. That means that insurance companies can’t restrict policies to cover less than what’s spelled out in the benchmark plan, even for individuals with expensive medical conditions.

And while, yes, states will probably not interpret these benefits as broadly as they could, the EHB bodes well for CAM providers. Take a look at the first benefit: Ambulatory Services. Services that help individuals for issues with motion or movement. Issues with movement, like, for example, back pain.

And it hardly needs to said that massage is a great solution for back pain.

This list, coupled with Section 2706, is very good news. The EHB says that back pain is a covered medical problem. Section 2706 says that any provider who is licensed to treat back pain can be covered under insurance, no matter if the provider is a medical doctor, a chiropractor, or a massage therapist.

Another benefit that jumps out is EHB #9: Preventative and wellness services and chronic disease management. As I said above, these benefits are very general and will be interpreted differently by different states, but it would be a stretch to suggest that CAM providers didn’t have something to offer for wellness services or chronic disease (eg, chronic pain).

The benchmark plans don’t need to be solidified until later in the year – enrollment in the Exchanges begin in October – but it’s important to pay attention now to how each state understands and addresses those benefits that have been deemed essential by the Affordable Care Act.

*From what I understand, states that have chosen to not accept federal funds for Medicaid expansion are not obligated to create a benchmark plan.


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