The National Association for the Advancement of Orthotics & Prosthetics (NAAOP) has issued the following update regarding the essential health benefits package under the Patient Protection and Affordable Care Act
The Institute of Medicine (IOM) today released a comprehensive report on the essential health benefits (EHB) package that small group and individual market health plans will have to cover beginning in 2014 under the Patient Protection and Affordable Care Act (PPACA). The report was commissioned by the U.S. Department of Health and Human Services (HHS) Secretary to advise her on major issues involving essential benefits. The key question for the O&P profession is whether O&P care will be considered “essential” when the Secretary issues a proposed rule later this year.
The report offers a mixed bag, but overall, it is fairly favorable from an O&P perspective. First, the IOM did not specifically recommend a standard benefits package. Instead, IOM focused on the process the Secretary should use in determining the contexts of the package. Key take-away recommendations of the IOM include the following:
- The HHS Secretary should start with the average health plan offered by small employers (as opposed to large employers, whose benefit packages are usually more generous) and build on the contents of the package in future years. Importantly, a coverage analysis commissioned by the American Orthotic & Prosthetic Association (AOPA) revealed that there is not much difference in the scope of O&P coverage between the typical small employer and the typical large employer (between 70 percent and 75 percent, respectively).
- Once the contents of a typical small-employer package are identified, the Secretary should look to the PPACA-mandated categories of benefits to ensure they are covered, including “rehabilitation and habilitation services and devices.” It is NAAOP’s belief that O&P care is considered covered under this category of benefits.
- Other provisions of the PPACA regarding nondiscrimination against any patient group should then be considered.
- The Secretary should determine an actuarial number that estimates the typical cost of a small-employer plan and manage the covered benefits to that estimate (in order to ensure the plan is affordable and, therefore, leads to the maximum number of people actually being able to afford new insurance coverage).
In addition, the IOM recommends that HHS establish a National Benefits Advisory Council to assist the Secretary in updating the contents of the EHB package in future years with a heavy reliance on evidence-based medicine, but fully considering other factors such as serving the diverse needs of patient populations.
NAAOP will be making its views on the importance of O&P coverage known to the HHS Secretary in a variety of ways in the coming weeks and months.
NAAOP will continue to keep its members and friends informed of developments as they occur. For more information, visit www.naaop.org or e-mail [email protected] Access NAAOP’s Congressional Legislative Action Center at www.naaop.org to communicate with your congressman or senator.