Health Care Reform Update, December 2010

Health Care Reform Update, December 2010

Posted By Scarlett Law Group || 13-Dec-2010

At the request of the Secretary of Health and Human Services (HHS), the Institute of Medicine (IOM) began undertaking a study that will make recommendations on the criteria and methods for determining and updating the essential health benefits package, which was passed as part of the Affordable Care Act. Recently, to help obtain public input, IOM asked for stakeholder comment in answering the following questions:

  • What is your interpretation of the word "essential" in the context of an essential benefit package?
  • How is medical necessity defined and then applied by insurers in coverage determinations? What are the advantages/disadvantages of current definitions and approaches?
  • What criteria and methods, besides medical necessity, are currently used by insurers to determine which benefits will be covered? What are the advantages/disadvantages of these current criteria and methods?
  • What principles, criteria, and process(es) might the Secretary of HHS use to determine whether the details of each benefit package offered will meet the requirements specified in the Affordable Care Act?
  • What type of limits on specific or total benefits, if any, could be allowable in packages given statutory restrictions on lifetime and annual benefit limits? What principles and criteria could/should be applied to assess the advantages and disadvantages of proposed limits?
  • How could an "appropriate balance" among the ten categories of essential care be determined so that benefit packages are not unduly weighted to certain categories? The ten categories are: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorders services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; pediatric services, including oral and vision care.
  • How could it be determined that essential benefits are "not subject to denial to individuals against their wishes" on the basis of age, expected length of life, present or predicted disability, degree of medical dependency or quality of life? Are there other factors that should be determined?
  • How could it be determined that the essential health benefits take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups?
  • By what criteria and method(s) should the Secretary evaluate state mandates for inclusion in a national essential benefit package? What are the cost and coverage implications of including current state mandates in requirements for a national essential benefit package?
  • By what criteria and method(s) should the Secretary evaluate state mandates for inclusion in a national essential benefit package? What are the cost and coverage implications of including current state mandates in requirements for a national essential benefit package?

BIAA thoughtfully crafted an answer to each question based on the idea that people with brain injury and other disabilities and chronic conditions should be guaranteed access to medically necessary treatment, including rehabilitation. BIAA detailed that for many people with brain injury and other disabilities and chronic conditions, rehabilitative and habilitative services and devices are essential medical interventions-equivalent to the provision of antibiotics to a person with an infection. Rehabilitation is the single most effective medical treatment known for securing neuroregeneration following brain injury and that reduction of disability via rehabilitation improves longevity; reduces disability and medical dependency and improves health outcomes and quality of life.

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