What is an “essential health benefit”?

The health care reform statute provides that “essential health benefits” must be defined to include the following categories of services:

  • Ambulatory patient services;
  • Emergency services;
  • Hospitalization;
  • Maternity and newborn care;
  • Mental health and substance use disorder services, including behavioral health treatment;
  • Prescription drugs;
  • Rehabilitative and habilitative services and devices;
  • Laboratory services;
  • Preventive and wellness services and chronic disease management; and
  • Pediatric services, including oral and vision care.

This list of benefits may be expanded in future regulations. Until the agencies issue guidance that clarifies the scope of essential health benefits, group health plans are subject to a “good faith” compliance standard in how they define essential benefits.

This list leaves open questions regarding whether many common plan limits are limits on “essential benefits.”  For example, many plans have a lifetime limit on infertility benefits.  Infertility benefits are not currently listed as an “essential benefit.”  However, some infertility benefits could include prescription drug and laboratory services, which are listed as “essential benefits” under the health care reform statute.  One way to approach this issue, pending further guidance, is to examine the underlying services associated with a particular limit and apply the limit only to those services not currently listed as essential health benefits.  You may need to consult with your insurance company or claims administrator for advice on these issues.

Today’s post was contributed by Maureen Maly and Jessica Faith.

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