CMSA Today - Issue 2, 2013 - (Page 14)

CMSA Case Management and the Law Gearing Up for More PPACA Reform BY GARRY CARNEAL, JD, MA An Abridged Look at Some Technical Changes Affecting Health Insurance Offerings L et’s be frank – you probably chose your profession to help coordinate and provide care to patients, and/or support case management programs across the continuum of care. Most likely, deciphering technical health care regulations and figuring out how they affect your job and your patients is not at the top of your daily to-do list. However, the Patient Protection and Affordable Care Act (PPACA) is transforming the health care system on many levels this year. Understanding how these reforms will affect health plans, providers, your patients, and of course, case managers is important. My last legal column highlighted how the PPACA-authorized State Exchanges will operate, and how they will affect insurance coverage for Americans. This time, let’s take a look at several new proposed rules just published by the U.S. Department of Health and Human Services (HHS) that outline how the federal government intends to implement essential health benefits, wellness coverage, and key insurance market reforms in each state. 14 CMSA TODAY Issue 2 • 2013 ESSENTIAL HEALTH BENEFITS As of Jan. 1, 2014, health plans that provide coverage to individuals and small groups must offer benefits and services covering 10 defined categories, known as essential health benefits (EHBs). These include: 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 10) Pediatric services, including oral and vision care The federal government is requiring that standardized EHBs be offered both within and outside of state-based Exchanges. To provide some flexibility, HHS is permitting each state to select an EHB package equal in scope to benefits offered by a “typical employer plan.” Each state will select a benchmark plan from one of four options: 1) The largest plan by enrollment in any of the three largest products in the state’s small group market 2) Any of the largest three state employee health benefit plan options by enrollment 3) Any of the largest three national Federal Employees Health Benefits Program (FEHBP) plan options by enrollment http://www.cmsa.org

Table of Contents for the Digital Edition of CMSA Today - Issue 2, 2013

President's Letter
Role of the Nurse Care Manager in a Patient-Centered Medical Home
Association news
View from Capitol Hill
Case Management and the Law
Ethics Casebook
Mentoring Matters
CMSA Corporate Partners
Index of Advertisers

CMSA Today - Issue 2, 2013

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