WASHINGTON — The Obama administration issued a final rule on Wednesday defining “essential health benefits” that must be offered by most health insurance plans next year, and it said that 32 million people would gain access to coverage of mental health care as a result.
The federal rule requires insurers to cover treatment of mental illnesses, behavioral disorders, drug addiction and alcohol abuse, and other conditions.
Kathleen Sebelius, the secretary of health and human services, said that in addition to the millions who would gain access to mental health care, 30 million people who already have some mental health coverage will see improvements in benefits.
White House officials described the rule as a major expansion of coverage. In the past, they said, nearly 20 percent of people buying insurance on their own did not have coverage for mental health services, and nearly one-third had no coverage for treatment of substance abuse.
The rule requires insurers to cover benefits in 10 broad categories, including hospital services, prescription drugs and maternity and newborn care.
Ms. Sebelius said the partial standardization of benefits would make it easier for consumers to compare health plans.
In the market today, she said, “it is difficult for consumers to make well-informed choices” because benefits, deductibles, co-payments and other features vary widely among competing health plans.
The rule says the new health insurance policies can be offered at four levels of coverage. Under the least generous policies, known as bronze plans, consumers will pay 40 percent of the costs of covered benefits, on average, and insurers will pay the rest. Under the most generous policies, known as platinum plans, consumers will pay 10 percent. The administration, however, declined to set a uniform national standard and allowed states to set many of the specific requirements.
Minimum benefits will vary from state to state, as each state will have a benchmark plan, reflecting coverage typically offered by employers. In more than 30 states, the benchmark, or standard, is an insurance plan offered by Blue Cross and Blue Shield.
Insurers in each state will generally be required to provide all benefits required by state laws adopted before Dec. 31, 2011. States can require additional benefits, but will have to pay the extra costs themselves.
Carl E. Schmid, deputy executive director of the AIDS Institute, an advocacy group, said he had hoped the federal government would set explicit, uniform national standards.
“We are disappointed,” Mr. Schmid said. “We thought the federal government would spell out essential health benefits in more detail. Patients respond differently to different drugs and often need multiple drugs at the same time. Under this rule, patients might have access to a total of 500 drugs in one state and more than 1,000 in another state.”
Access to autism treatment may also differ. Stuart Spielman, senior policy adviser at Autism Speaks, an advocacy group, said that 32 states had laws requiring coverage of autism treatments and that other states were considering legislation to impose such requirements.
The rule limits the costs to consumers in several ways. For health plans offered in the small-group market, the deductible amount, paid by consumers before insurance kicks in, generally cannot exceed $2,000 for individual coverage and $4,000 for family coverage. Total out-of-pocket costs will also be subject to limits. If a health plan has a network of doctors and hospitals, consumers may be required to pay more if they go outside the network.
The new rule generally applies to all health insurers offering coverage in the individual and small group markets. States will have primary responsibility for enforcing the standards. The federal government said it would step in if it found that a state was not doing an adequate job of protecting consumers.
Federal officials acknowledged that many policies sold in the individual insurance market did not cover all the services required in the new rule. The administration said that many small business health plans “meet or are close to meeting the coverage requirements.”
Under the rule, health plans must provide benefits that have not always been provided by commercial insurers. For example, insurers must cover dental care and vision services for children, as well as “habilitative services” to help people with disabilities keep or improve their skills.
A version of this article appeared in print on February 21, 2013, on page A16 of the New York edition with the headline: New Federal Rule Requires Insurers to Offer Mental Health Coverage .
Article By ROBERT PEAR | THE New York TIMES | Published: February 20, 2013
http://www.nytimes.com/2013/02/21/health/new-federal-rule-requires-insurers-to-offer-mental-health-coverage.html?smid=tw-share&_r=0
The federal rule requires insurers to cover treatment of mental illnesses, behavioral disorders, drug addiction and alcohol abuse, and other conditions.
Kathleen Sebelius, the secretary of health and human services, said that in addition to the millions who would gain access to mental health care, 30 million people who already have some mental health coverage will see improvements in benefits.
White House officials described the rule as a major expansion of coverage. In the past, they said, nearly 20 percent of people buying insurance on their own did not have coverage for mental health services, and nearly one-third had no coverage for treatment of substance abuse.
The rule requires insurers to cover benefits in 10 broad categories, including hospital services, prescription drugs and maternity and newborn care.
Ms. Sebelius said the partial standardization of benefits would make it easier for consumers to compare health plans.
In the market today, she said, “it is difficult for consumers to make well-informed choices” because benefits, deductibles, co-payments and other features vary widely among competing health plans.
The rule says the new health insurance policies can be offered at four levels of coverage. Under the least generous policies, known as bronze plans, consumers will pay 40 percent of the costs of covered benefits, on average, and insurers will pay the rest. Under the most generous policies, known as platinum plans, consumers will pay 10 percent. The administration, however, declined to set a uniform national standard and allowed states to set many of the specific requirements.
Minimum benefits will vary from state to state, as each state will have a benchmark plan, reflecting coverage typically offered by employers. In more than 30 states, the benchmark, or standard, is an insurance plan offered by Blue Cross and Blue Shield.
Insurers in each state will generally be required to provide all benefits required by state laws adopted before Dec. 31, 2011. States can require additional benefits, but will have to pay the extra costs themselves.
Carl E. Schmid, deputy executive director of the AIDS Institute, an advocacy group, said he had hoped the federal government would set explicit, uniform national standards.
“We are disappointed,” Mr. Schmid said. “We thought the federal government would spell out essential health benefits in more detail. Patients respond differently to different drugs and often need multiple drugs at the same time. Under this rule, patients might have access to a total of 500 drugs in one state and more than 1,000 in another state.”
Access to autism treatment may also differ. Stuart Spielman, senior policy adviser at Autism Speaks, an advocacy group, said that 32 states had laws requiring coverage of autism treatments and that other states were considering legislation to impose such requirements.
The rule limits the costs to consumers in several ways. For health plans offered in the small-group market, the deductible amount, paid by consumers before insurance kicks in, generally cannot exceed $2,000 for individual coverage and $4,000 for family coverage. Total out-of-pocket costs will also be subject to limits. If a health plan has a network of doctors and hospitals, consumers may be required to pay more if they go outside the network.
The new rule generally applies to all health insurers offering coverage in the individual and small group markets. States will have primary responsibility for enforcing the standards. The federal government said it would step in if it found that a state was not doing an adequate job of protecting consumers.
Federal officials acknowledged that many policies sold in the individual insurance market did not cover all the services required in the new rule. The administration said that many small business health plans “meet or are close to meeting the coverage requirements.”
Under the rule, health plans must provide benefits that have not always been provided by commercial insurers. For example, insurers must cover dental care and vision services for children, as well as “habilitative services” to help people with disabilities keep or improve their skills.
A version of this article appeared in print on February 21, 2013, on page A16 of the New York edition with the headline: New Federal Rule Requires Insurers to Offer Mental Health Coverage .
Article By ROBERT PEAR | THE New York TIMES | Published: February 20, 2013
http://www.nytimes.com/2013/02/21/health/new-federal-rule-requires-insurers-to-offer-mental-health-coverage.html?smid=tw-share&_r=0
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