Short Takes On News & Events

Feds Outline What Insurers Must Cover, Down To Polyp Removal

By Julie Appleby

February 20th, 2013, 12:50 PM

The Obama administration on Wednesday released its final rule on essential health benefits, which sets out what benefits insurers must offer starting in 2014.

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 mainly to individual and small group plans. They also apply to plans provided to those newly eligible for Medicaid coverage.

A few provisions also affect self-insured plans and large group plans offered by employers. Limits on the maximum out-of-pocket costs a consumer would face each year, for example, would apply to all policies.  That amount would be $6,250 for a single policyholder and $12,500 for a family based on this year’s rate. The 2014 number is expected to be slightly higher.

The final, 149-page rule 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.

Responding to concerns from some advocacy groups, the final rule also states that insurers must have procedures to allow patients to get “clinically appropriate” prescriptions not on the plan’s list of covered medications.

“This is an improvement,” said Stephen Finan, director of policy for the American Cancer Society Cancer Action Network. “It suggests that if you need a drug and that’s not on the formulary, you can get it, which was not the case before.”

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.

20 Responses to “Feds Outline What Insurers Must Cover, Down To Polyp Removal”

  1. Hunt Turner says:

    What garbage. I guess free enterprise is gone or our government is trying to kill it.
    We elected these dictatorial people and I think it is time to get rid of them.
    This is a perfect illustration of how our government wants to control us.
    It is time to say NO!!!

  2. “At lease one drup per therapeutic category” Most drug formularies have more than just one. It will be interesting to see if thing like fertility have to covered. Then a plan would have to have at least one drug that is covered. What kind of increase could we see? What about growth hormone drugs?

  3. pappy says:

    Free enterprise? Are you kidding? Do you mean the free enterprise healthcare system that (for decades) American citizens have paid twice as much as citizens in any other nation on earth? Huh? Is your idea of a successful free enterprise healthcare system a system that excludes over 50 million Americans and renders another 25 million who are underinsured? Huh? Is that the free enterprise that you love so much? We have “enjoyed” your style of free enterprise healthcare for decades and what do we have as a result? The most expensive healthcare in the world by double with over 50 million Americans that can’t afford to participate and another 25 million that are underinsured. That’s what your free enterprise gave us! The free enterprise you love so much has done its very best to ruin healthcare in America while raking in as much in profit as they possibly can in the process. Free enterprise? Don’t make me laugh! The American consumer has been raped and abused for decades by the free enterprise healthcare system that you seem to love so much!

  4. killroy71 says:

    And when you wonder why your premium goes up next year, here’s why. And because the premiums go up and so much is covered, people will be even MORE diligent about getting their money’s worth of health care, driving premiums higher….you get the picture. In this kind of culture, it doesn’t matter whether we have single payer or not, nothing is slowing down this cost freight train.

  5. The number of essential benefits and preventive services wouldn’t bother me so much if I thought they would actually improve health and/or save money. Many of the mandatory inclusions simply aren’t supported by solid, scientific-based evidence. I hope someone has been appointed by the ACA to determine if all the services and products that have been deemed “essential” actually prove to be beneficial to a majority of people.

  6. pappy says:

    “In this kind of culture”…

    Culture? Huh? Do you mean the culture of mandating that all Americans buy private health insurance? Is that the “culture” you are talking about? The culture that says, no more free rides at the emergency room? That culture? The culture that says people will get their healthcare from their own personal primary care doctor and not from a team of expensive doctors and nurses in a hospital emergency center? That culture? The culture that says everyone pays copays, co-insurance and deductibles? That culture? A culture that mandates participation from every American instead of just the people that have been paying premiums and carrying the load for decades? That culture? As I see it, with everyone buying insurance, with everyone seeing a personal doctor or nurse practitioner, with everyone paying copays, with everyone paying deductibles, with everyone paying co-insurance, with everyone getting much better care and becoming more and more healthy, the “culture” that you hate so much will be the “culture” that eventually rescues our troubled healthcare system over time. Of course, short sighted people will always be short sighted. Especially on the Republican side.

  7. Jeff says:

    Jeez…Take a deep breath Pappy…let me guess you have a bunch of bumper-stickers on the trunk of your Outback. Obamacare is the last nail in the entitlement coffin that this country is being buried in. One day (hopefully while shopping for healthcare in Bolivia) the liberals of this once great country will wake up and wonder what happened…although they’ll probably just blame someone else.

  8. Bonnie Langer says:

    Skimmed the .pdf. Here’s the rub. Anyone who CURRENTLY has healthcare coverage is NOT included in the basics. Grandfathered in. Mandated basic coverage/scripts apply only to NEW policies as of 2014. Good luck with that!

  9. PARanger says:

    Hey…just wanted to chime in…I spent many years fighting for this once great country to give all of us the right to say and believe what we want. However, the climate in our country is not one where everyone gets to say what they want….In terms of health care, yes our system is broken, and let me say first I do believe it is, and should always be our rights as citizens of this country to recieve emergent treatment, but evry little scratch does not need a doctors visit…..what ever happened to self accountability, whatever happened to people treating their colds, and stubbed toes themselves….I’ll tell you what happened, as our country progressed and became more civilized we quit expecting people to do their part….we started saying “oh I’m sorry your fat” or “I’m sorry you didn’t get that B you wanted but I’ll make the test easier next time so you can make the grade”….What is this crap, it is the weakening of our internal constitution. We can’t continue to give it all away, we have to expect people to step up to the plate also…..Work hard, be rewarded for your work….decide not to do the work and fail to get the reward….Quit blaming each other and take responsibility….I do pretty well in this world, but I have workedvery hard and can from the very bottom to this point, why should I not expect other to do the same….
    Please tell me how this is wrong….And as far as gevernment is concerned whether you are Democrat, Republican, or other….I’m American, and governemnt is broken, need repealed and re-booted….lets get back to the basics, and things will work out for another 200 or so years until liberal do-gooder types start telling everyone they have the right to have it all without making the effort…..AMEN !!!!!

  10. Barbara says:

    Nurse says: “Many of the mandatory inclusions simply aren’t supported by solid, scientific-based evidence. ”

    That’s right. Having prenatal care and delivery in a hospital isn’t supported by solid, scientific based evidence! The working poor should just keep crossing their fingers that their babies are ok and deliver in the ER if that home delivery doesn’t work out for ya.

    Ya – and about that emergency care. It hasn’t been proved by solid, scientific-based evidence that going to the ER when you have paralysis on one side. You should be having that stroke at home and just deal with it yourself. Same goes for those namby pambies who get hit by a car. Stop you bleeding your own damn self.

    Stop drinking the koolaid. The 10 essential services meet basic health care needs. There are so many plans out there now that don’t cover basic services. People don’t find out until it’s too late that their premiums don’t cover much at all – if anything. Even car insurance has bare minimum coverage levels – it’s time health insurance did too!

  11. Barbara, I’m very happy that the ACA is addressing the problem of standardizing health care coverage, and at first glance the list of 10 essential benefits looks promising. However, if you look at a detailed list of what is included under each benefit, some of what is mandated goes beyond basic health care needs, such as breast pumps for new mothers and screening tests of debatable value.

    No doubt this list will change over time. My concern is that unless the HHS is very careful about mandated coverage, and avoids manipulation by special-interest lobbyists, the cost-benefit ratio will get out of whack and our premiums will become (even more) unaffordable.

  12. Olivia says:

    Entitlement coffin? Obamacare mandates that the freeloaders in society buy private insurance and actually pay real money out of their own pocket for their healthcare. It’s an idea that originated with the ultra-conservative Heritage Foundation some 20 years ago. It became Mitt Romney’s claim to fame with Romneycare. It was an idea that, like Obamacare, mandates all Americans buy “private” health insurance from “private” insurance companies, not government insurance companies (if there could ever be such a thing). What about that sounds like “entitlement”? You simply have no argument and that’s why you make no sense!

  13. Let’s follow a logical path throught this mess. Take a family of 4, making 54,000 per year who has not been insured. To get their coverage, they will pay $331.58 per month in premium, (subsidized to the tune of $662.00 by the rest of us, hence the term entitlement).
    If they make $90,000, the subsidized premium will be $712.00

    When they go to the doctor (instead of the emergency room) for the first time, they will be asked to pay a co-pay, if the doctor prescribes a medicine they will be asked to pay a co-pay at the drug store. A month later they will get a bill that says none of that was actualiy covered, because they had to pay their deducatble and furthermore, the insurance only pays 60% your bills anyway.

    How long do you think it will take for them to remember how to find the emergency and pay a little fine?? I think the whole plan will work like a charm, don’t you?

    Check premiums right here:
    http://healthreform.kff.org/SubsidyCalculator.aspx

  14. pappy says:

    “How long do you think it will take for them to remember how to find the emergency and pay a little fine?? I think the whole plan will work like a charm, don’t you?”

    Uh, yeah! Like we see happening in Massachusetts where (in just 6 short years) the number of uninsured dropped to about 6 percent compared to the rest of the nation at about 16 percent? Is that the kind of “work like a charm” you are talking about?

    http://www.kff.org/healthreform/upload/8311.pdf

  15. The PPACA is the result of a watered-down, rule-laden mess of a good idea gone wrong. Only universal health care can do what we need in this country. It doesn’t even have to be single-payer. Multiple payer can be fine, with universal health care plans at the core. Check out the universal health plans in other wealthy, industrialized democracies, like Germany, UK, Japan, France and more — including the remarkable Taiwan. For a thorough eye-opener, just browse through TR Reid’s “The Healing of America.” Each time I hear a politician state that “America has the best health care in the world,” I feel disgust at that self-deluding platitude. We can do so much better for the monetary outlay. Indeed, our country could benefit greatly from proven models of universal health care.

  16. William says:

    Sadly, we will not see universal healthcare any time soon. Not while we continue to have Neaderthals in the Congress and their tea party constituents like we see posting here. The knuckle-draggers will keep spreading their lies about how Obamacre can never work in spite of the evidence of success we see in Massachusetts. We were very fortunate to have the “other” Mitt Romney as a trailblazer in progressive healthcare. The “other” Mitt Romney gave us a taste of what could be possible for all Americans. Romneycare is a resounding success by any measure. Did it need tweaks over the past 6 years? Of course! Will it continue to need tweaks? No doubt! Bottom line? Obamacare is a carbon copy of Romneycare. That’s good news! Will Republicans ever admit that their Heritage Foundation mandate idea was a good idea? Not while Obama is President.

    By the way, nice shot Pappy!

  17. pappy says:

    “The PPACA is the result of a watered-down, rule-laden mess of a good idea gone wrong.”

    Ask any doctor about the “rule-laden mess” they deal with on a daily basis with private insurers. Most doctors would like to see a better system than what we’ve had in the past. Private insurers second guess doctors on a regular basis. The PPACA would be worse? Frankly, doctors will agree that it can’t get any worse. Doctors will welcome the standards that the PPACA will bring. The PPACA will level they playing field so that the rules you seem to hate so much will apply equally to everyone across the board. Doctors understand Medicare because Medicare offers one set of rules for all seniors. Today, unlike in the Medicare world, doctors have hundreds of private insurers with thousands of different rule books with tens of thousands of different rules about what is permitted and what is not. Now that’s what I call a mess! With the PPACA, there will be onc single set of rules that all private insurers must play by. In the future, doctors will be relieved to learn one rule book. Not hundreds of different and diverse rule books coming from hundreds of different private rule makers that arbitrarily change those rules several times in a year whenever they please. Doctors want things to be standardized so that treatment will be easier to administer. Today, doctors don’t know which rules apply to which patients. In the future, with the PPACA, doctors will better understand the game because we won’t be playing soccer and baseball and football and tennis and basketball, all at the same time and all with a different set of rules.

  18. pappy says:

    “The PPACA is the result of a watered-down, rule-laden mess of a good idea gone wrong.”

    Ask any doctor about the “rule-laden mess” they deal with on a daily basis with private insurers. Most doctors would like to see a better system than what we’ve had in the past. Private insurers second guess doctors on a regular basis. The PPACA would be worse? Frankly, doctors will agree that it can’t get any worse. Doctors will welcome the standards that the PPACA will bring. The PPACA will level they playing field so that the rules you seem to hate so much will apply equally to everyone across the board. Doctors understand Medicare because Medicare offers one set of rules for all seniors. Today, unlike in the Medicare world, doctors have hundreds of private insurers with thousands of different rule books with tens of thousands of different rules about what is permitted and what is not. Now that’s what I call a mess! With the PPACA, there will be one single set of rules that all private insurers must play by. In the future, doctors will be relieved to learn one rule book. Not hundreds of different and diverse rule books coming from hundreds of different private rule makers that arbitrarily change those rules several times in a year whenever they please. Doctors want things to be standardized so that treatment will be easier to administer. Today, doctors don’t know which rules apply to which patients. In the future, with the PPACA, doctors will better understand the game because we won’t be playing soccer and baseball and football and tennis and basketball, all at the same time and all with a different set of rules.

  19. YPPAP says:

    Pappy, be glad mental health is an “Essential Benefit” at least you might get some treatment for your Democratic dementia. Since you have so much free time (obviously you’re not working) and on the government dole this is a dream come true. Since it’s the rest of us paying for you free loaders you ought to back off a bit and stop biting the hand that feeds you. Sorry don’t want to become your pen pal as I do have a job. Don’t expect a reply to whatever nonsense you use to rebut my comments.

    To your health!

  20. tina says:

    Yppap,

    Just because someone posts more than once on a specific thread, so that makes them “on the government dole”? That sounds like Romney’s 47 percent comment. Fact is, Republicans are filled with assumptions regardless of whether most of them are false. I guess that’s why the vaginal probe assumption or the voter ID assumption took off like a rocket, huh? Rebut your comments? We already did. Voters made that rebuttal heard at the voting booth. Better luck in 2014…

    You’ll need it!

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