The U.S. Department of Health and Human Services (HHS) recently announced that states could define benefits under the Affordable Care Act (ACA), the federal health care law enacted in 2010, by choosing one of several state and federal health care plans as a reference. The plan each state chooses could have significant impact on the coverage of autism interventions.
HHS is encouraging public input on its intended approach. To help the autism community respond, Autism Speaks has analyzed the HHS proposal as it relates to autism coverage. Comments should be directed to HHS by January 31, 2012, to EssentialHealthBenefits@cms.hhs.gov.
Under the HHS proposal, the health care plan a state chooses would serve as its standard for all health care plans, whether they operate inside the health insurance exchange created in the state, or in individual and small group health care plans offered outside the exchange. The benchmark plan would set benefits for all health care services, including autism interventions.
The ACA directs HHS to define essential health benefits (EHB) – a set of core health services. Certain health plans would then have to cover those benefits beginning in 2014. Those plans include: individual and small group health plans that were not in effect the day the law was signed in 2010; Medicaid benchmark and benchmark-equivalent; and Basic Health Programs (optional state programs for individuals and families with incomes between 133 and 200 percent of the federal poverty limit).
The law provides that the EHB include items and services within the following 10 benefit categories:
1. Ambulatory patient services
2. Emergency services
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
States must pay the cost of any benefits required by state law that go beyond the EHB. In a challenging economy, states may be reluctant to assume the cost of additional services, so what is covered in the EHB really matters.
With the stated aim of balancing “comprehensiveness, affordability, and state flexibility while taking into account public input throughout the process of establishing and implementing EHB,” HHS for 2014 and 2015 gives states a choice of four benchmark plan types:
1. the largest plan by enrollment in any of the three largest small group insurance products in the state’s small group market
2. any of the three largest state employee health benefit plans by enrollment
3. any of the three largest national Federal Employees Health Benefits Program plan options by enrollment
4. the largest insured commercial non-Medicaid health maintenance organization (HMO) operating in the state
If a state chooses a benchmark subject to state mandates, that benchmark would include those mandates in the state EHB package. HHS intends to assess the benchmark process for 2016 and beyond and may exclude some state benefit mandates from the state EHB package.
HHS will require states to supplement coverage if a benchmark plan is missing one of the 10 categories of benefits. For example, if a state’s benchmark plan does not cover habilitative services, such as speech therapy for a child with autism who is not talking at the expected age, HHS could require the plan to add that care.
HHS is considering two specific options for benchmark plans that do not include coverage for habilitative services:
1. requiring habilitative services to be offered at parity with rehabilitative services, or
2. letting plans decide which habilitative services to cover
Under the second option, plans would report their coverage decisions to HHS, which would evaluate them and further define habilitative services in the future. This option might give plans discretion to refuse coverage for autism.
Another concern is applied behavior analysis (ABA). All plans must cover mental health and substance use disorder services, including behavioral health treatment, and HHS acknowledges that mental health parity applies in the context of EHB. Many of the benchmark plans will follow state law that makes ABA a covered benefit. But what if a benchmark plan does not cover ABA? HHS has provided no guidance, even though the ACA demands this care. (Reference A, B)
HHS intends to require that a health plan offer benefits that are “substantially equal” to the benefits of the benchmark plan selected by the state and modified as necessary to reflect the 10 coverage categories. In other words, HHS will allow insurance companies some flexibility to adjust benefits, including the specific services covered. Allowing substitution within or across coverage categories introduces more uncertainty – it could either enhance or dilute autism services.
To respond to the HHS proposal, send your comments by January 31, 2012, to EssentialHealthBenefits@cms.hhs.gov.