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"Essential Benefits" Will Lead to More Patients for Some Providers

In a 2009 speech to the American Medical Association, President Obama promised, “If you like your health-care plan, you’ll be able to keep your health-care plan, period. No one will take it away, no matter what.” This declaration came as the health care law was being written and similar statements were repeated by the President after the bill became law.

By August, waves of cancellation notices were being mailed to policy holders stating that they could not keep their current health care plan, after all. This came as no surprise to those in the insurance and health care industry who have spent countless hours working to implement Affordable Care Act (ACA) provisions. It was inevitable that many policies would have to be cancelled in light of the ACA’s ten essential health benefits provision and ban on pre-existing conditions.

A key part of the ACA is that private insurance companies must provide ten areas of coverage, including:

n  Ambulatory patient services

n  Emergency services

n  Hospitalization

n  Maternity and newborn care

n  Mental health and substance use disorder services, including behavioral health treatment (including counseling and psychotherapy)

n  Prescription drugs

n  Rehabilitative and habilitative services and devices

n  Laboratory services

n  Preventive and wellness services and chronic disease management

n  Pediatric service

As announced in the cancellation notices, current plans that do not meet these standards cannot, for the most part, be sold after 2013.[1] The uproar that ensued after Americans began receiving notices led the President to issue a policy reversal and delay penalties. Now, people content with their current policies can keep them, despite the non-conformity, for another year. But the President did not have the final word on the issue. His proposal granted discretion to insurers to decide whether customers could stay on their existing plans; there is no guarantee that insurers will do so, or that the state insurance commissioners will allow such renewals. In Kentucky, Governor Beshear gave insurers the power to decide whether they would honor current plans.

What does all this mean for providers? One of the President’s biggest talking points when selling the ACA to the American people was that individuals would be allowed to keep their doctors and their health plans. It is no doubt surprising and frustrating for those individuals who are now finding out they must find a new plan. However, for providers whose services have historically been excluded from plans, this change could generate more business. For example, now that mental health care is an essential health provision, mental health care providers may see an increase in individuals seeking their services.

In 2011, the Department of Health and Human Services noted: “62 percent of enrollees do not have coverage for maternity services; 34 percent of enrollees do not have coverage for substance abuse services; 18 percent of enrollees do not have coverage for mental health services; 9 percent of enrollees do not have coverage for prescription drugs.” Services like these that have long been considered non-essential are finding their way back into the spectrum of comprehensive health plans via the ACA.  According to the Obama administration, the ACA will provide one of the largest expansions of mental-health and substance-use disorder coverage in a generation.

While the cancellation of policies may come as a shock to some people, perhaps they will be presently surprised with the increased range of services and providers they can now access. It may be the incentive that would encourage people to go ahead and see what other options are available, even if it is permissible to keep current plans for another year.

[1] Policies that existed before the ACA was passed in March 2010 are known as grandfathered plans; these plans can avoid some of the new standards, but it is up to insurers and employers to decide whether they will keep offering them. If a grandfathered plan has undergone minimal changes within the last three years, such as an increase in premiums, the grandfathered status can be lost.

Services may be performed by others.

This article does not constitute legal advice.

Lexington, KYLouisville, KYFrankfort, KY: MML&K Government SolutionsWashington, D.C.