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Final health benefit rules clarify some confusion

The Obama administration cleared up some confusion on Wednesday about rules governing just which health services insurance companies have to pay for.

The Obama administration cleared up some confusion on Wednesday about rules governing just which health services insurance companies have to pay for.

For instance, if you get a colonoscopy and the doctor finds a pre-cancerous growth and removes it, that still counts as a cancer screening and you won’t have to pay anything for it. And mental health services must also be fully covered, the Health and Human Services Department says in its final version of the of the so-called essential health benefits rules.

The final rules harden up draft rules published last November, after taking into account thousands of comments. As the 2010 Affordable Care Act requires, insurers will no longer be able to dump patients who are starting to cost too much, they won’t be able to charge women more than men, they have to cover anyone who can pay and they’ll have to pay for maternity care, birth control, eye exams for kids and for mental health services.

They also must provide cancer screening free of charge, but Stephan Finan, senior policy director of the American Cancer Society Cancer Action Network, said there was some genuine confusion over some issues, such as colonoscopies. During a colonoscopy, a tiny camera is guided through the colon, along with a device that can remove any suspicious-looking growths then and there.

Sometimes when this happened, doctors would re-classify the colonoscopy as a diagnostic procedure instead of a screening service, Finan said. Patients could then be on the hook for a co-pay or even for several  hundred dollars  if they had to pay co-insurance. “They have clarified that,” Finan said in a telephone interview.

The rules also make it clear a patient getting a test for the BRCA gene, which raises the likelihood of breast and ovarian cancer, gets both the test and counseling about it for free.

HHS also issued a report detailing how the new rules will greatly broaden coverage of mental health and substance abuse services.

“The Affordable Care Act will provide one of the largest expansions of mental health and substance use disorder coverage in a generation,” Sherry Glied, assistant secretary for planning and evaluation, and colleagues wrote in the report.

“Beginning in 2014 under the law, all new small group and individual market plans will be required to cover 10 Essential Health Benefit categories, including mental health and substance use disorder services, and will be required to cover them at parity with medical and surgical benefit.”

HHS estimates that nearly 20 percent of people who buy insurance do not get mental health coverage included, and nearly a third don’t get coverage for substance abuse disorders. The new rule re-classifies both as essential benefits that insurance companies have to pay for.

HHS says 47.5 million Americans have no health insurance, and a quarter have a mental health condition or substance use disorder -- or both. About 27 million of them will get health insurance by 2017 thanks to the health reform law, the Congressional Budget Office projects.

The final rule doesn’t affect all insurance companies. The requirements apply to individual and small group plans, especially those sold on the new health insurance exchanges, which are online marketplaces for people to buy insurance starting in October, and taking effect in 2014.

They’ll also apply to anyone getting Medicaid for the first time. But they don’t apply to self-insured health plans, and that means a big chunk of people who get health insurance through their work. Finan estimates that 60 percent of people who are covered by an employer are covered by self-insured plans.

“About 35 million Americans will benefit in the individual and small-group market,” Finan says.

The final regulations also clarify prescription coverage. Insurers must pay at least partly for all clinically appropriate drugs, something Finan praises. “Some of these cancer drugs can cost anywhere between $50,000 and $100,000 a year,” he says. If they weren’t all covered as essential health benefits, some patients may have been on the hook for all or most of that cost.

“A lot of plans today have no out-of-pocket limits, which is why a lot of cancer patients are financially stressed, even if they have health insurance,” Finan says. “That is one of the big gains for cancer patients under the Affordable Care Act.”

Finan isn’t happy about everything in the rules. They let states use “benchmark” insurance plans to help them decide what to require as essential health benefits outside of the federal guidelines, and then only for 2014 and 2015. After that, it’s not clear what will happen. “We would like to see much more uniformity and standardization of benefits coverage,” Finan says.

The Children’s Hospital Association was also unhappy, saying the rules did little to improve pediatric benefits.

“The Association is also disappointed that the administration has not provided a strong definition of habilitative services for children, which means that children with special health care needs may not have access to the services they need,” it said in a statement.

“The Association is very concerned that the flexibility HHS has given states to select services to include in essential health benefits packages could result in the exclusion of critical services for children, particularly those with severe disabilities and lead to state-by-state disparities.”

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