What is your interpretation of the word “essential” in the context of an essential benefit package?
The official response from APTA:
“Essential,” in the context of essential benefits provided under insurance plans, should mean benefits that are available and accessible to all individuals with coverage without increased premiums and co-payments. Essential benefits include, but are not limited, to preventing the spread of disease, improving and/or eradicating certain medical conditions or disease states, improving and minimizing the effects of acute and chronic conditions, injury prevention, health benefits which promote and encourage healthy behaviors and mental health, and assuring quality and accessibility to these services. Without such essential benefits, an individual’s health condition would deteriorate and potentially require even more costly healthcare resources.
Under section 1302(b) of the Patient Protection and Affordable Care
In comments submitted to the Institute of Medicine (IOM) last week, APTA provided a definition of “essential” in the context of essential benefits, offered clarification on what constitutes rehabilitative services, discussed how “medical necessity” is defined and applied by insurers in coverage determinations, and made various recommendations related to the types of services that should be included in benefit packages. In response to a question on limits on specific or total benefits, the association said, “APTA believes imposing numeric limits on essential benefits is inappropriate given the provisions included in the Affordable Care Act that prohibits annual or lifetime limits on essential benefits. However, it is important to appreciate that unlimited treatment that is of no value is not appropriate. Medical necessity and effectiveness of care are important principles to keep in mind.” APTA also commented on the need for essential health benefits to take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups.