Obesity and Essential Health Benefits: The Final Rule

February 21st, 2013 by MorganDowney Leave a reply »

The Department of Health and Human Services issued final regulations defining “Essential Health Benefits” which will have to be included in insurance programs listed on state exchanges and all non-grandfathered health insurance plans in the group and individual markets. The EHB covers 10 categories covering hospitalization, prescription drugs, etc. See Fact Sheet.

The regulation is generally close to the proposed regulation with the exception of expansion of mental health, habilitative care and pediatric dental and vision services.

Last July, interim final regulations were issued which require these plans to include under prevention and wellness, the US Preventive Services Task Force recommendations, which include Intensive Behavioral Counseling for Adult Obesity.

Unfortunately, it appears that HHS has no problem with allowing most state exchanges to use “benchmark” plans which exclude bariatric surgery, according to a report by the Obesity Care Continuum. Coverage of prescription medicines for obesity is murky. The EHB regulations state that plans must provide at least one drug in each category or class of the US Pharmacopeia. But it uses version 5.0 for Medicare. Under the Medicare statute, Part D, drugs to treat obesity are excluded so they don’t appear to be covered. However, this might be challenged under the EHB rules that the benefits must be designed in a manner which does discriminate based on age, disability, or expected length of life and must take in the needs of a diverse population.

The regulations limit deductibles to $2,000 for individual coverage and $4,000 for family coverage.

The STOP Obesity Alliance and my own comments, had argued for more clarity in the inclusion of obesity treatments.


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