Monday, August 15, 2011

Q & A on Essential Health Benefit

Confused about healthcare reform?  You’re not alone – it’s complicated! To shore up your understanding of some basic concepts or provisions in the Affordable Care Act (ACA), we’ll include a single question and answer each week.  Send your suggestions about which concepts, terms, key dates or other aspects of healthcare reform you’d like a Q and A on in future editions of Federal Fridays via e-mail to 
We’ll start this week with a question about the Essential Benefit Package.    
Q:   What is most important to understand about the “essential benefit package”?
A:  To help standardize health insurance policies and coverage, Congress included a list of 10 items and services as the “essential benefit package” in the Affordable Care Act.  This list is only an outline however, and the difficult task of further defining the amount and scope of these essential benefits was left up to the Secretary of HHS to clarify through future regulations.
The law also requires the benefit package to be “like a typical employer-based plan”.   Advocates and other stakeholders have been speculating about how HHS will interpret all of this, and hope to see the proposal (regulation) before the end of 2011. Note that the essential benefits will be required in all individual and small group policies sold as of 2014  as well as new Medicaid coverage. 
10 Essential Health Benefits categories required under the Affordable Care Act:
  • 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
  • Pediatric services, including oral and vision care

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