This post continues where two posts on Insurance Claims Issues Blog left off, the first one on Monday, May 21, 2012 and the second on Wednesday, May 23, 2012.
Congress expressed its clear intent in the ACA statutes that "preventive health services" must be included among "essential health benefits" --and that the Secretary of Health and Human Services must fill in gaps with rules and regulations that Congress intended would be more specific than the statutory language.
"Essential health benefits" are described in general terms in Section l302(b) of the ACA [42 U.S.C. § l8022(b)]:
(b) ESSENTIAL HEALTH BENEFITS.
(1) IN GENERAL.-Subject to paragraph (2), the Secretary shall define the essential health benefits, except that such benefits shall include at least the following general categories and the items and services covered within the categories:
(A) Ambulatory patient services.
(B) Emergency services.
(C) Hospitalization.
(D) Maternity and newborn care.
(E) Mental health and substance use disorder services, including behavioral health treatment.
(F) Prescription drugs.
(0) Rehabilitative and habilitative services and devices.
(H) Laboratory services.
(i) Preventive and wellness services and chronic disease management.
(j) Pediatric services, including oral and vision care.
[Emphasis added.]
"Preventive health services" are special, or at least they are treated that way in the ACA and in the Regulations which it generated. Section 1001 of the Affordable Care Act adds section 2713 of the Public Health Service Act, which in turn amends Part A, Title XXVII, Public Health Service Act [42 U.S.C. § 300gg et seq.]:
SEC. 2713 [42 U.S.C. 300gg-13]. COVERAGE OF PREVENTIVE HEALTH SERVICES.
(a) IN GENERAL.-A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for
(1) evidence-based items or services that have in effect a rating of 'A' or 'B' in the current recommendations of the United States Preventive Services Task Force;
(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and [sic]
(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. [; and]
(4) with respect to women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph.
(5) [F]or the purposes of this Act, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around November 2009.
[EMPHASIS ADDED.]
To be continued on Insurance Claims and Issues Weblog at www.insuranceclaimsissues.typepad.com, including the story of how the Affordable Care Act contains NO EXEMPTIONS for Employers required by the ACA to offer Plans and Policies which contain coverage for women's health, INCLUDING OFFERING COVERAGE FOR CONTRACEPTIVE SERVICES, whereas the Regulations DO.
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