Implementing the Essential Health Benefits Requirement in New Jersey: Decision Points and Policy Issues
Rutgers Center for State Health Policy/Seton Hall University School of Law, Center for Health & Pharmaceutical Law & Policy (with funding from the Robert Wood Johnson Foundation), August 2012
48 Pages Posted: 20 Sep 2012
Date Written: August 1, 2012
An important feature of the Affordable Care Act (“ACA”) is its requirement that most individual and small group insurance policies beginning in 2014 guarantee coverage of, at minimum, a slate of ten “essential health benefits” (“EHB”): (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services, including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care. Some of these categories of covered services are familiar to most existing coverage; it is rare to find a health insurance product that does not cover hospitalization and emergency services. Others are increasingly common, including prescription drugs and preventive care. Others are poorly covered or absent in some existing private insurance, including mental health and habilitative services.
Delineation of these categories of services is intended to assure consumers and small businesses purchasing coverage after 2014 that the coverage will be comprehensive, providing key services at appropriate levels to address serious health conditions. Listing the categories of services was only the beginning of providing that assurance, however. Much of the detail of what must be covered was left to the regulatory process. The process by which the EHB requirements have been and will be fleshed out, and the means by which the requirement will be monitored and enforced, will require substantial attention at the federal and state levels. This Issue Brief describes the statutory content of the EHB requirement, the federal regulatory process that is adding specificity to the requirement, and New Jersey’s substantial role in the regulatory process. The manner in which the ACA and federal guidance are interpreted by the State and by insurance carriers can assure consumer access to services essential to their health and well-being.
Keywords: essential health benefits, Affordable Care Act, New Jersey
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