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Perspectives on Essential Health Benefits Workshop Report (2012) / Chapter Skim
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8 Non-Discrimination in the Required Elements for Consideration
Pages 85-90

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From page 85...
... to articulate standards for benefit design and coverage determinations to modify "what has been histori cally at the discretion of insurers." Specifically, this section of the law addresses having balance among categories of care and not having coverage decisions, reimbursement rates, incentive programs, or benefits that discriminate based on age, disability, or expected length of life. This discretion relates not only to individual medical necessity decisions, but also to coverage design at the macro level.
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From page 86...
... For example, the Secretary could conceivably instruct insurers and plan administrators to utilize the terms and definitions in their most popular group health products as long as such terms and definitions do not discriminate on the basis of disability by, for example, defining a benefit as covered only in cases in which restoration or recovery are possible. This approach to tempering delegated authority is consistent with other laws, such as the Mental Health Parity Act, 9 which gives insurers and health plans discretion over whether to cover mental illness and substance use disorder benefits but prohibits the use of discriminatory quantitative and non-quantitative coverage limits.
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From page 87...
... A medical necessity standard limited to medical conditions, for instance, could be interpreted as not addressing coverage of treatments for developmental disabilities because they are often not considered medical conditions. There are, however, medical treatments, including speech therapy and physical therapy, appropriate for children with developmental disabilities.
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From page 88...
... Sabin asked if it would be discriminatory for an insurer, for example, to acknowledge that children with autism spectrum disorders have severe speech delays, but regard those delays as an "educational problem." In response, Ms. Rosenbaum cited a case in which an employer-sponsored plan administrator decided that certain types of treatments for a particular child with developmental disabilities were educational in nature and were therefore excluded from reimbursement.15 All of the treatments in question were medical treatments furnished by medical professionals in a clinical setting.
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From page 89...
... 2011. The essential health benefits provisions of the Affordable Care Act: Implications for people with disabilities.
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Key Terms

  • expected length
  • essential health
  • medical treatments
  • medical necessity
  • underlying condition

  • health benefits
  • developmental disabilities
  • affordable care
  • benefit design
  • physical therapy

  • coverage determinations
  • plan documents
  • medical conditions
  • plan administrator
  • reasonable clinical

  • rosenbaum cited
  • parity act
  • inherently discriminate
  • services based
  • coverage design

  • decision based
  • health insurance
  • patient protection
  • rosenbaum noted
  • health parity

  • care act
  • benefit statute
  • senate bill
  • decisions suggest
  • benefits provisions


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