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ObamaCare Clusterfuck: "Essential benefits" to be determined randomly by state


States will be given wide latitude to decide what “essential benefits” insurers must offer in their health policies come 2014, the Obama administration said Friday in a move that pushes off final federal rules on the topic until an unspecified date.

Essential benefits, which must be offered by insurers in most policies sold to individuals and small businesses, are one of the key flash points in the federal health law. Patient advocates have called for a broad national standard covering a wide range of treatments, while business groups have said affordability must be a top consideration, even if it means a more limited package.

The long-awaited guidance gives states four choices for designing a benchmark insurance package. Regulators can base their package on the benefits offered by: one of the three largest state employee health plans (by enrollment); one of the three largest federal employee health plan options; the largest HMO plan offered in the state or one of the three largest small-group plans in the state.

Health and Human Services Secretary Kathleen Sebelius said the plan shows how the Obama administration intends to move forward – and reflects its commitment to giving states flexibility.

“Coverage that works in Florida may not work in Nebraska,
so this approach allows states to tailor their package to the needs of their own residents,” said Sebelius, who did not give any specific examples of differences in the medical treatments that might be needed by residents of one state versus another.

Well, maybe I'm just ignorant here -- that could be! -- but "works" for whom? I can see how coverage might no't "work" for insurance companies state to state, but why patients? Is the suffering cancer in Florida different from the suffering from cancer in Nebraska?

And now the bureaucratic detail:

All insurance plans sold to individuals and small businesses will have to cover items and services in a minimum of 10 categories defined by the 2010 law, including preventive care, emergency services, pediatric care, including oral and vision care, maternity care, hospital and physician services, and prescription drugs. Self-insured employers are exempt from the essential benefit requirement, but most large employer plans already cover those 10 broad categories.

Outside the 10 categories, the law leaves specifics up to the regulators who design the essential benefit package. Those might include particular treatments that will be covered or restrictions on such things as the number of office visits, drugs or services that will be covered. The federal law restricts annual dollar limits on coverage and bars lifetime dollar limits.

States that don’t choose one of the four options for defining an essential benefits package will have one selected for them by federal regulators, who plan to use the benefits offered by the small-group plan with the largest enrollment in the state.

Friday’s guidance covers only the benefits that must be offered in each state. Rules to be released later will address other aspects of coverage, such as deductibles and copayments for office visits, drugs and other services.

Something to watch!

Rather than issue a proposed regulation, the administration chose to advise the states through a bulletin. That does not have the force of law, but neither can it be quashed by Congress, as could a rule. By putting out the choices as a form of guidance, the administration also does not have to provide definitive economic estimates of the proposal or determine its regulatory impact on small businesses.

A maneuver that sleazy can come to no good.

Maybe somebody, some Obot, can explain to me how a system that delivers health care randomly by state delivers health care as a right (which Obama agrees it is). Is the right to free speech different in Nebraka and Florida? Freedom of religion? Quartering troops in homes?

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Submitted by Dromaius on

So now insurers have (1) full control of rate-setting on these plans via discluding providers who don't agree to their quasi-Medicaid rates; (2) control over the "essential benefits". Yes, they do! Because if states attempt to put any kind of controls on them, insurers will threaten to leave the state unless they get what they want. I know this, because we have experience it in my state in the past.

The only way to reign in insurers is via national controls that they either have to put up with or leave the industry. Anything else is a gimme to them.

quixote's picture
Submitted by quixote on

insurers will threaten to leave the state unless they get what they want

Hah. And there I was, like Lambert, wondering how in hell human physiology varied across states. Those of us who keep thinking it's about care when it's about insurance will keep making these mistakes.