Feds Outline What Insurers Must Cover, Down To Polyp Removal

The Obama administration on Wednesday released its , which sets out what benefits insurers must offer starting in 2014.

Insurers must cover 10 broad categories of care, including emergency services, maternity care, hospital and doctors’ services, mental health and substance abuse care聽and prescription drugs.

Essential benefit requirements apply mainly to individual and small group plans. They also apply to聽plans provided to those newly eligible for Medicaid coverage.

A few provisions also affect self-insured plans and large group plans offered by employers. Limits on the maximum out-of-pocket costs a consumer would face each year, for example, would apply to all policies. 聽That amount would be $6,250 for a single policyholder and $12,500 for a family based on this year鈥檚 rate. The 2014 number is expected to be slightly higher.

The final, 149-page rule retains requirements that insurers offer , or the same number as a state鈥檚 benchmark plan, whichever is greater. Many state benchmark plans require at least two drugs per class.

Responding to concerns from some advocacy groups, the final rule also states that insurers must have procedures to allow patients to get 鈥渃linically appropriate鈥 prescriptions not on the plan鈥檚 list of covered medications.

鈥淭his is an improvement,鈥 said Stephen Finan, director of policy for the American Cancer Society Cancer Action Network. 鈥淚t suggests that if you need a drug and that鈥檚 not on the formulary, you can get it, which was not the case before.鈥

Advocates had wanted the government to require coverage of a broader range of drugs, but insurers and others said requiring many more would raise premium costs. The final rule says 鈥減lans are permitted to go beyond the number of drugs offered by the benchmark.鈥

The final rule also clarifies that insurers , even if a polyp is found and removed. Wednesday鈥檚 rule . Earlier rules allowed .

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