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Health insurers' interpretations of "essential benefits" may vary


Two of the Affordable Care Act's most popular features are the ability for people to get healthcare coverage without regard for preexisting conditions, and the requirement that health plans cover 10 "essential benefits."*

But there's a catch. Insurance firms can still pick and choose which specific therapies they'll cover within some categories of benefit, reports Kaiser Health News. And the way insurers interpret the rules could turn out to be a big deal for people with disabilities who need ongoing therapy to improve their day-to-day lives.

Suppose you have a condition like cerebral palsy, as Bryce Vernon does, a 20-year-old film student in Los Angeles. A   special computer mounted to his wheelchair tracks his eye movements. Using his eyes, he can indicate on a screen what letters and words he wants the computer's voice to say. A speech-language pathologist helps him use the technology to maintain a productive life.

The healthcare Vernon is getting, called "habilitative services," is expensive, and not all insurance plans have it in the past. 

But while habilitative services are listed among the ACA's 10 essential health benefit. there are no guarantee that new insurance plans on the healthcare exchange will offer them. Insurers are allowed room to interpret the services for each of the essential categories. For example, a provider might cover physical therapy if you break a bone, but not cover long-term support for a chronic condition such as speech therapy for a child with developmental delays. 

Jiggering benefits in this way can have the effect of discouraging people with costly chronic conditions from signing up, says the report. 

Net net for consumers: When shopping for a healthcare plan on the exchange, you'll need to read the fine print and ask "what if" questions about every benefit offered.

Just like today. Read the story.

 * The 10 essential benefits include emergency services, hospitalizations, laboratory services, maternity care, mental health and substance abuse treatment, outpatient or ambulatory care, pediatric care, prescription drugs, preventive care, rehabiltative and habilitative services, vision and dental care for children.  


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