The health reform law has spawned many new terms related to its provisions, such as ‘‘individual mandate’’ and ‘’health insurance exchanges.’’
Here’s another one: ‘‘essential health benefits.’’
The Affordable Care Act requires all insurance plans to offer a comprehensive set of benefits starting in 2014. States are allowed to choose a benchmark plan that would define those benefits that are considered essential.
Georgia insurance department official Jay Florence said Tuesday that the agency is reviewing potential benchmark plans offering coverage to individuals and small businesses.
Florence spoke at an Atlanta panel discussion on the Affordable Care Act’s impact on Georgia children, sponsored by the Georgia Children’s Advocacy Network and Voices for Georgia’s Children.
The federal Department of Health and Human Services has identified a benchmark plan for Georgia, a small-group policy offered by Blue Cross and Blue Shield of Georgia, Florence said. That plan would be the default benchmark if the state does not choose one.
“We are unsure whether we’ll make an election or go with HHS,’’ he said. He also noted the Blue Cross plan does not cover pediatric vision and dental services, two of the essentials under the law.
While Tennessee is holding public hearings on the benefits standard, Georgia does not plan to do so, Florence said. But he added that the agency will accept input on the issue from interested parties.
All insurance plans sold to individuals and small businesses will have to cover items and services in a minimum of 10 categories defined by the 2010 law, including preventive care, emergency services, pediatric care, including oral and vision care, maternity care, hospital and physician services, and prescription drugs. Self-insured employers are exempt from the essential benefit requirement, but most large employer plans already cover those 10 broad categories, Kaiser Health News reported.
Outside the 10 categories, the law leaves specifics up to the state regulators who design the essential benefits package. Those may include particular treatments that will be covered or restrictions on such things as the number of office visits, drugs or services that will be covered, KHN reported. Eventually, decisions will be made on the basic plan’s deductibles and copayments for office visits, drugs and other services.
The benefits decisions are perhaps most important to people with chronic health conditions.
“We know that historically some cancer patients have not received all of the services necessary to fully treat their condition,’’ said Stephen Finan, senior director of policy for the American Cancer Society Cancer Action Network.
“The essential health benefits requirement is a vital step toward ensuring that coverage will be based on what is medically necessary and appropriate to treat a condition, rather than arbitrary limits that sometimes exist in health plans offered today,’’ he said.
States need to develop the essential benefit packages as part of their work to establish online health insurance exchanges, set to open in 2014.
Also at the panel discussion, supporters of the Affordable Care Act pointed out that the law already has helped thousands of Georgia children.
An HHS regional director, JoAnn Grossi, cited the 123,000 young Georgians who were enabled to stay on their parents’ health plans till age 26; insurers being barred from excluding child coverage due to pre-existing conditions; and the elimination of lifetime limits on benefits.
Other benefits for Georgia children include $8.7 million for early childhood assessment visits to at-risk families, and $1.5 million for school-based health centers, added Matthew Wright of the consumer advocacy group Voices for America’s Children.
But much of the debate at the panel presentation was on the state’s upcoming decision on Medicaid: whether or not to expand the program for low-income residents.
Blake Fulenwider, deputy commissioner of the Department of Community Health, reiterated Gov. Nathan Deal’s statement that no decision on Medicaid expansion will be made till after the November election.
The expansion, if Georgia decides to go through with it, would add more than 600,000 low-income residents to the Medicaid rolls. But it would come at an ultimate cost of more than $4 billion over a 10-year period, Fulenwider said.
“The rate of uninsured in the state is a problem,’’ he said. He also raised questions about whether the state could afford the 10-year outlay.
Dr. Harry Heiman of Morehouse School of Medicine, a member of the audience, questioned whether the state had done an evaluation of the benefits of a Medicaid expansion, and whether it had assessed the costs to people’s health if expansion is not implemented.
Grossi, the HHS director in the Mid-Atlantic region, pointed to a Maryland report that found implementation of the Affordable Care Act will benefit that state’s budget by more than $600 million through 2020, generate more than $3 billion in annual economic activity, and create more than 26,000 jobs.
Yet an expansion would mean more work for the already beleaguered caseworkers who help sign up Medicaid enrollees, said Jonathon Duttweiler, manager for Medicaid eligibility at the Georgia Department of Human Services. “We have less staff than we had 15 years ago to do casework,’’ he said.
With expansion, the caseload would increase by about 400 enrollees per state worker, from about 571 per state worker now, if staffing remains the same, he said.