Sunday, February 10, 2013

One of the most hailed benefits of the Patient Protection Affordable Care Act (PPACA) passed in 2010 was the elimination of pre-existing exclusions. These exclusions have been used by insurance companies to delay or eliminate certain conditions from being covered by the individual's group healthcare policy. In the case of group coverage the normal delay for coverage would range from 12 – 18 months depending on when the individual enrolled in the group coverage.

However what is not mentioned, when the benefits of the PPACA are trumpeted, is that insurance companies will be able to exclude coverage for certain conditions and this will not be a violation of the pre-existing exclusion removal mandate.

The PPACA requires insurance carriers provide coverage for Essential Health Care Benefits. The PPACA defines Essential Health Care Benefits in Section 1302(B) as:

[E]ssential health 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.

G) 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.

The details of what these services include have not been released by the Department of Health and Human Services. Currently every state has their own regulations regarding mandated benefits insurance carriers must provide to sell policies in their state. It is possible that some conditions not covered under the federal guidelines will be mandated coverage at the state level.

So let's look at an example. Several years ago I had a client who had TMJ. However his TMJ was not the routine TMJ but a very special form. The medical insurance provider stated it was not covered under the medical insurance because that particular diagnosis was a dental issue. The dental insurance provider stated that particular diagnosis was a medical issue and therefore not a covered service and denied coverage. The surgery to correct the problem was estimated at $15,000. The PPACA will not prevent this same situation from reoccurring.  The PPACA will allow carriers to exclude coverage for certain medical conditions and treatments as long as those services are not mandated under the Essential Health Benefits or state mandated coverage guidelines.

This "loophole" makes it vital that every employer read carefully the "excluded coverage's" from their policies. It is possible you could have an employee who has a current medical condition that may be excluded. Employees and employers have been lead to believe that carriers will have to cover all pre-existing conditions. That assumption is not true if that particular condition is excluded from coverage.