"Isn't that covered by ObamaCare?" Public understanding of the Affordable Care Act has not been great, with a fair amount of confusion about key provisions and benefits detected by surveys.
On the micro-level, for members and shoppers of exchange plans -- a population expected to reach 20 million in a few years -- as well as commercial plan members, coverage for specific services in the broad, 10 category collection of essential health benefits is one such area ripe for misunderstanding.
Among the numerous priorities in consumer education and outreach, in fact, the national patchwork of essential health benefits could be especially vexing.
Essential health benefits are mandated by the ACA, but under the Centers for Medicare & Medicaid Services transitional policy, states have been given the ability to choose EHB "benchmark" plans for 2014 and 2015. That means consumers in different states have access, or lack thereof, to different services, medications and treatments across a range of health conditions, as University of Pennsylvania health researchers Janet Weiner and Christopher Colameco detail in a new study.
The ACA's essential benefits include primary and outpatient care, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse services, prescription drug, rehabilitative and habilitative services, laboratory services, preventive and wellness services, and pediatric services, including oral and vision care.
When it comes to specific coverage areas within those broad categories, though, there is a lot of variation, Weiner and Colameco found in an analysis of EHB benchmark plans.
Forty-five states require coverage of chiropractic services, while 26 require autism treatment coverage -- although advocates in more states are taking insurers to court to guarantee coverage for applied behavior analysis in autism.
For healthy eating and activity services, benchmark plans also vary, with 25 states requiring nutrition counseling coverage and 23 requiring bariatric stomach surgery, but only five require coverage for weight loss management.
Among other clinical areas, 31 states require coverage for treatment of temporomandibular joint and muscle (or jaw) disorders, 26 require coverage of hearing aids, 19 require coverage of infertility treatments.
For the 2016 plan year, CMS is planning to reevaluate the policy of delegating EHB benchmarking to states. Until then, the variation is bound to persist, unless insurers take it upon themselves to offer coverage for services that members expect or demand.