Essential Health Benefits and the Affordable Care Act

Family Voices (National logo)

This article reposted with permission from National Family Voices.

Affordable Care Act: Essential Health Benefits & Habilitative Services 

by Brooke Lehmann and Janis Guerney

The Department of Health and Human Services (HHS) recently issued a proposed regulation that, among other topics, addresses the “Essential Health Benefits” that must be included in certain health plans pursuant to the Affordable Care Act (ACA).  The proposed regulation raises serious concerns about the availability of “habilitative” services-therapies and devices that help individuals to acquire or maintain skills or function.

BACKGROUND: The ACA requires that a package of “Essential Health Benefits” (EHB) be covered in all health insurance plans sold in Exchanges and in all non-grandfathered individual and small group policies for plan years beginning in or after 2014.

ACA Essential Health Benefits List:

Girl receiving injection from female doctor
Image courtesy of David Castillo Dominici / FreeDigitalPhotos.net
  • ambulatory patient services
  • emergency services
  • hospitalization
  • maternity and newborn care
  • mental health and substance use disorder services
  • prescription drugs
  • rehabilitative and habilitative services and devices
  • laboratory services
  • preventive/wellness services and chronic disease management
  • pediatric services, including oral and vision care

The Department has proposed that each state establish its own set of EHBs, based on a “benchmark” plan selected from one of four types of plans sold in that state (e.g., largest small group plan, largest HMO).  If a state fails to select a benchmark, then the default will be the largest small group plan in the state.  About half of the states have already identified their benchmark choices, which must be made by December 26.

HABILITATIVE BENEFITS:  With respect to habilitative services, the proposed rule is quite troublesome.  If the state’s benchmark plan does not include any habilitative services, the state would be able to define that benefit.  But HHS does not provide guidance about how states should do so.

If a state declines to define habilitative services, then insurance plans will determine the benefit.  Each plan must either provide habilitative services that provide parity with rehabilitative services, or establish its own set of habilitative benefits and report them to HHS.

If insurers get to define habilitative services without any parameters, each one will have an incentive to provide minimal benefits, so that its plan will not attract a disproportionate number of people who need costly habilitative services.

Family Voices and other groups will be submitting comments on the proposed regulation and we urge others to provide public comments on benefits that are important to CYSHCN.   Submit comments by 12/26 at
http://www.regulations.gov/#!docketDetail;D=CMS-2012-0142.
Contact the FV Policy Team with any questions:
Brooke Lehmann, MSW, Esq.: blehmann@familyvoices.org or 202-333-2770
Janis Guerney, Esq.: jguerney@familyvoices.org  or 202-546-0558

Learn more about Essential Health Benefits at this page.

Early Intervention: A stitch in time…

Have you ever noticed how many proverbs and sayings relate to thinking ahead? A stitch in time saves nine. A penny saved is a penny earned. Look before you leap. An ounce of prevention is worth a pound of cure.

Early Intervention Colorado logoWhen it comes to children’s healthy development, there’s a step between prevention and “cure,” and it comes in the form of Early Intervention. Over the years, health care professionals have found that identifying delays in development, whether physical, cognitive, or behavioral, and diagnosis of ongoing health conditions at an early age, and addressing them immediately, can make a tremendous difference in long-term outcomes. Because this is not only better for the child and family, but also more cost-effective, than waiting until more serious problems develop later in life, many early intervention services are publicly funded, meaning that families do not have to pay directly for thingsBaby Corrine & Grandma like speech, physical, or occupational therapy.

Anyone can refer a child for screening to find out if they are eligible for early intervention services, whether you are a family member, doctor, child care provider, or other concerned individual. Visit http://www.eicolorado.org/ or call 888-777-4041 to talk to someone at Early Intervention Colorado about the process of making a referral, or the services and supports available.

The Rockwell Family Story: Fighting to keep everyone safe

The Rockwell family lives in Littleton, except for their daughter, “Sarah,” who has intense mental health needs and has lived in a residential treatment center for the past several years. The Rockwells approached Family Voices Colorado in 2009 with concerns that Medicaid wanted to send Sarah home, in spite of psychiatric assessments that acknowledged neither she nor her family would be safe if that happened.

Sarah’s parents had already tried to appeal the decision, but encountered one roadblock after another in getting the different public agencies and private companies involved to acknowledge the severity of Sarah’s condition or to take responsibility for continuing to fund her care. Sarah’s mom, Irene, was at her wit’s end as to what would happen if her daughter came home, but did not want to follow one caseworker’s suggestion that she relinquish her parental rights so that the Department of Child Protective Services would take over.

Bringing the right people to the table

Business meeting
Image courtesy of Ambro / FreeDigitalPhotos.net

Family Voices was able to help the family gather the appropriate institutional representatives at the table (Medicaid Managed Care Ombudsman, Department of Health Care Policy and Financing, Behavioral Healthcare, Inc., and the residential treatment center) for many meetings of evaluation and negotiation. Finally, the team secured the appropriate documentation from Sarah’s care providers and psychiatrist to convince the funding agencies of the medical necessity of continuing Sarah’s placement, without having to reevaluate the situation on a monthly basis.

Irene, who prides herself on her resourcefulness, has taken the lessons she learned from working with Family Voices to become an advocate for other families facing similar struggles with the health care system.

Support and empowerment

Dina Castro, Family to Family Coordinator
Dina Castro, Family to Family Coordinator (shown here at the 2011 Walk ‘n’ Roll), has worked with the Rockwells for three years

Family Voices helps to move parents beyond the isolation, grief and panic they often feel when learning their child has a disability or chronic condition, or when trying to navigate the various service systems, and puts those parents back in control of their lives and their children’s welfare. Through working with Family Voices, parents are supported and empowered, resulting in stronger families and an increased ability to advocate effectively on behalf of their children.

Families of children with special healthcare needs often access multiple private and public systems. Consequently, they experience the system limitations more quickly than those whose needs are not as numerous or recurrent. By building partnerships among professionals and these families, Family Voices promotes improved decision-making, better outcomes and higher quality healthcare for everyone the systems serves.

Colorado Gives Day is December 4, 2012
Support Family Voices on Colorado Gives Day

Please help Family Voices Colorado continue to support and empower families like the Rockwells by making a donation at GivingFirst.org/FamilyVoicesCODecember 4, 2012, is Colorado Gives Day, when the FirstBank Incentive Fund increases the value of every dollar contributed. You can also set up a recurring gift to provide ongoing support throughout the year. Together, we can make Colorado a better place for children with special health care needs.

Making Colorado a better place for children and youth with special health care needs