Kaiser Health News is reporting that insurers must cover 10 broad categories of care, including emergency services, maternity care, hospital and doctors’ services, mental health and substance abuse care and prescription drugs.
Essential benefit requirements apply to individual and small group plans sold within and outside the new online, state-based exchanges scheduled to launch in 2014. The requirements also apply to benefits provided to those newly eligible for Medicaid coverage. These requirements do not apply to self-insured health plans, which is how most large companies cover their employees.
The final, 149-page rule says insurers must have procedures to allow patients to get “clinically appropriate” prescriptions which are not included on the plan’s list of covered medications. It also retains requirements that insurers offer at least one drug per therapeutic category, or the same number as a state’s benchmark plan, whichever is greater. Many state benchmark plans require at least two drugs per class.
Advocates had wanted the government to require coverage of a broader range of drugs, but insurers and others said requiring many more would raise premium costs. The final rule says “plans are permitted to go beyond the number of drugs offered by the benchmark.”
The final rule also clarifies that insurers cannot charge consumers a co-pay for a screening colonoscopy, even if a polyp is found and removed. Wednesday’s rule finalizes proposals published in November. Earlier rules allowed states to choose their own benchmark benefit plans.