Friday, April 13, 2012

Will acupuncture be an EHB?

It shouldn't be surprising that an assortment of practitioners offering certain medical services would like to get their particular specialties declared essential health benefits (EHBs). EHBs are those medical services that non-grandfathered plans in the individual and small group markets, both inside and outside the state exchanges, must cover beginning in 2014. The Patient Protection and Affordable Care Act (ACA) instructs that the EHB must equal the scope of benefits provided under a typical employer plan.

Now, the American Association of Acupuncture and Oriental Medicine (AAAOM) has urged the public to support its drive to have acupuncture designated an EHB,which would most certainly generate a substantial amount of business for acupuncture clinics across the nation. According to a page on the organization's website, at, at least 5,758 letters and e-mails were sent to the HHS in support of the AAAOM's position prior to the January 2012 deadline. It will be interesting to see how many other groups outside conventional Western medicine will attempt to have their services considered part of mandatory coverage by 2014.

After considering public input and recommendations from the Institute of Medicine (IOM), the Health and Human Services Department (HHS) has decided that EHB may be defined by any of an assortment of benchmark plans selected by each state, one of which includes the largest plan of any of the three largest small group insurance plans in the state, which the HHS has decided will be the default choice for states that do not exercise the option to select a benchmark plan. The other choices for each state will be any of the largest three state employee health benefit plans, any of the largest three national Federal Employee Health Benefits Program (FEHBP) plans and the largest commercial non-Medicaid HMO in the state.
The HHS has determined that small group plans cover generally the same services as the FEHBP Blue Cross Blue Shield Standard Option and the Government Employees Health Association (GEHA), but those last two plans cover acupuncture, and small group health plans generally don't. Consumer groups had urged the HHS to spell out specific covered benefits and provide uniformity in benefits packages offered by different states, but health insurers and employers pushed for mere general guidance, which would give them more flexibility.
HHS has decided that health insurers will have flexibility to adjust specific covered services in all ten statutory EHB categories. Those ten categories are: (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; and (10) pediatric services, including oral and vision care. It's possible, then, that even if the HHS doesn't grant the AAAOM's request, various health insurers could determine that acupuncture fits at least one of the above categories, or states could choose a benchmark such as the FEHBP plan that would cover it. If a state chooses a small group market plan, however, it looks like acupuncture would not be covered for state citizens in the exchanges, and if acupuncture is part of mandated state coverage, the cost of it would have to be covered by the state.
According to the AAAOM, acupuncture fits the HHS' definition of an EHB, including criteria numbers (1), (4), (5), (7), and (9) above. Organizations such as the Center for Inquiry (CFI) have, however, written to the HHS asking that it deny the AAAOM's request based on its assertion that acupuncture does not meet the IOM's criteria for EHB, which mandate that any EHB be safe, medically effective, demonstrate meaningful improvement, be a medical service, and be cost effective.

So, for the moment, it looks like coverage of acupuncture, if there's to be any at all, will vary by state, especially since it's unlikedly that the HHS will do as consumer groups requested and spell out specific covered benefits. However, the AAAOM can take comfort in the ACA's requirement that the HHS update EHB, based on changes in medical evidence or scientific advancement.

For a comprehensive analysis of the ACA, and additional information on health reform and other developments in employee benefits, just click here.


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