Health-Plan Details Unveiled

February 21, 2013

The Wall Street Journal

Jennifer Corbett Dooren

Health-insurance plans that cover tens of millions of Americans will have to pay for mental-health and substance-abuse treatments starting next year under federal rules the Obama administration finalized Wednesday.

The provision, part of the 2010 Affordable Care Act, requires health plans for individuals and small businesses to cover 10 categories of services, including prescription drugs, maternity care and physical rehabilitation. Many of the specifics of what is covered in those categories will be left to states to decide.

Insurers and some business groups have argued that mandating such coverage would make policies too expensive, and they had lobbied the federal government to scale back the scope of what needs to be covered.

But if anything, the final regulations released Wednesday beefed up the requirements for certain services beyond what regulators proposed in November. Neil Trautwein, a vice president at the National Retail Federation, said language regarding the scope of mental-health service that insurance plans must cover appears stronger than previously proposed.

"Just because you require an insurance plan to cover it doesn't mean you can buy that coverage," said Katie Mahoney, executive director, health policy at the U.S. Chamber of Commerce. Insurance plans offered by most large employers aren't affected by the requirements.

Insurance companies had been waiting for the regulations from the Department of Health and Human Services—along with others still to come—before finalizing products and pricing them. State insurance regulators have to approve each plan.

People with low and moderate incomes will get subsidies to offset the cost of buying insurance that will be sold on state and federal insurance exchanges, or marketplaces, starting Oct. 1. The subsidies will be offered on a sliding scale for people who earn about four times the federal poverty level—about $94,000 for a family of four—or less.

Consumer groups cheered the rules, saying the government didn't budge under pressure from business and insurance groups to pare coverage.

"We are a giant step closer to all people—particularly people with chronic health conditions—having access to meaningful coverage," said Marc Boutin, executive vice president at the National Health Council, an organization that includes health and patient-advocacy groups.

Chris Hansen, the president of the American Cancer Society's Cancer Action Network advocacy affiliate, said the prescription-drug rules are an improvement over the administration's initial proposal by stating patients need access to new drugs as they are approved.

Groups representing specific conditions, such as autism, had hoped that federal rules would guarantee insurers must cover their services. But the Obama administration effectively averted such picking and choosing by letting states benchmark their minimum benefits based on existing health plans sold in the state. Autism Speaks, an advocacy group, said so far only half the states planned to include the therapy.

The AIDS Institute, a nonprofit advocacy group, said it is concerned that patients will have varying access to drugs depending on the state they live in.

For pediatric dental coverage, which the law requires, Wednesday's rules left consumer groups worried that the dental plans will be too expensive.

The rules say consumers can be charged a "reasonable" out-of-pocket maximum, which would be in addition to any out-of-pocket expenses allowed under a medical plan.

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