Essential Benefits Package Found Favorable for O&P Profession

The Institute of Medicine released a comprehensive report on the essential health benefits package that small group and individual market health plans will have to cover beginning in 2014 under the Patient Protection and Affordable Care Act. The report was commissioned by the Health and Human Services (HHA) 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.

According to a National Association for the Advancement of Orthotics & Prosthetics (NAAOP) press release, the report offers a mixed bag but, overall, it is fairly favorable from an O&P perspective. First, the Institute of Medicine (IOM) did not specifically recommend a standard benefit 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, according to the NAAOP, 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;
  • Once the contents of a typical small employer package are identified, the Secretary should look to the Patient Protection and Affordable Care Act (PPACA) mandated categories of benefits to ensure they are covered, including rehabilitation and habilitation services and devices. NAAOP stated 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; and
  • 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 NAAOP release stated that the IOM recommends that HHS establish a National Benefits Advisory Council to assist the Secretary in updating the contents of the essential health benefits 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.

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