Are Health Reform’s Essential Benefits Not So Essential?

by Cathy Miller on December 20, 2011

in Health Care Legislation, Health Care Reform


It’s one of the provisions of the Affordable Care Act where everyone seemed to have an opinion.

What health care services deserve essential benefits status?

  • There are 10 categories
  • Individual/small group health plans in state Exchanges must offer them
  • All Medicaid plans must offer them
  • The provision is effective in 2014

The tricky part was what services should be included in those categories. HHS sought the opinion of the Institute of Medicine (IOM).

This political hot potato has landed back in the laps of the states.

States’ Turn

The Department of Health and Human Services (HHS) recently announced that the states will determine what constitutes essential benefits.

Whether that’s good or bad depends on which side of the reform bill you fall on.

Not surprisingly, HHS Secretary, Kathleen Sebelius presents it as “the federal government’s commitment to give states flexibility as they set up the exchanges.”

Health reform advocates get a little twitchy at leaving such an important provision up to the individual states.

Top Ten List lists the 10 categories that essential benefits must include.

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  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, and
  10. Pediatric services, including oral and vision care

Any proximity to the political season is purely coincidental.

The decision has once more divided the consumer camps to the business group sponsor versus the individual consumer. Businesses will campaign for a limited list of services in each category, while individual consumers put more coverage on their holiday wish list.

2014 should certainly be an interesting year.

BigStock Photo credit


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Notice of Disclaimer –Cathy Miller is not an attorney and cannot provide legal advice. The information provided is for your general background only, and is not intended to constitute legal advice as to your specific circumstances. We recommend you review legislation with legal counsel.

{ 2 comments… read them below or add one }

Kristen December 30, 2011 at 10:59 pm

Very interesting–I wonder how much the states will vary on their top ten lists… I could see something like mental health being overlooked…
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Cathy December 31, 2011 at 11:21 am

Hi Kristen: My understanding is the categories stay the same. It’s which covered services fall under the categories that is the $65.000 question.


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