The Affordable Care Act’s (ACA) Essential Health Benefits (EHB) completely changed health coverage by requiring health plans on the individual and small-group market to cover the same ten benefits without discrimination. These 10 essential categories of benefits range from general—office visits and hospital care – to more specific population focused requirements, including pediatric care, mental health and substance use disorder services. However, CMS, health plans and state regulators have experienced challenges bringing this robust standard to life resulting in inconsistent implementation across states.
A recent report by the American Occupational Therapy Association (AOTA) found some concerning issues with the coverage of the rehabilitation and habilitation services and devices EHB found in the marketplace. While the report finds that only a minimal percentage of plans were counted as discriminatory, about a third of plans combined their rehabilitation benefit with their habilitation benefit. Combining rehabilitation with habilitation coverage can restrict consumers with disabilities who utilize this benefit and who are inherently at risk of discriminatory benefit design, health treatment and health disparities. CMS has recognized this issue and has required plans to keep the benefit limits of rehabilitation and habilitation services separate starting January 2017.
Beyond the benefits analyzed in the AOTA report, the recently finalized Section 1557 rule gives examples of other benefit design practices that CMS has recognized as discrimination, including arbitrary age limits and placing medications on the highest cost-sharing tiers. Nonetheless, Section 1557 still leaves a lot of room to determine discriminatory benefit design on a case-by-case basis. Therefore, robust monitoring and enforcement of EHB standards (and other relevant federal rules) plays an important protective role to ensure that consumers get the full benefits promised to them.
Making the health coverage feedback loop work better
AOTA’s report can be a handy resource to check states’ marketplace plan coverage of rehabilitation and habilitation services and devices. On a broader level, its findings suggest a need for a more systematic way to monitor benefit design and take corrective action – such as strengthening the feedback loop between consumer assisters, consumers, advocates, state departments of insurance and the Office of Civil Rights (when the issue is based on discrimination); improving the consumer complaints process; and, sharing findings of discriminatory benefit design.
As more and more people gain coverage through the marketplaces, it is critical that they, especially the most prone to discrimination, get the care they need. Fulfilling the promise of the ACA’s 10 EHBs not only ensures that people with health conditions and disabilities have access to coverage, but also that they are no longer excluded from necessary and effective treatments on the basis of their health status. While Section 1557 provides the regulatory framework to protect consumers, consumer advocacy is still a key ingredient to truly make non-discriminatory benefit design a reality.