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Health Insurance Regulations Should Be Specific, Report Suggests Health Insurance Regulations Should Be Specific, Report Suggests

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Health Care / health care

Health Insurance Regulations Should Be Specific, Report Suggests

photo of Margot Sanger-Katz
October 6, 2011

Simply providing a broad list of health services that must be covered by an insurance company can lead to wide variations in interpretations, a study in Colorado has found.

The study by Colorado health officials examined implementation of a state law that required all preventive health services to be fully covered by insurers, with no costs to patients. The law stressed preventive services that were scored as important by the U.S. Preventive Services Task Force, an independent panel of experts whose judgments are also the basis of a similar provision in last year’s national health care reform law.

The Colorado team found that insurance programs shared an understanding of the guidelines in certain categories, but had very different interpretations when it came to smoking cessation, obesity prevention, and colon cancer screening. Restrictions in some plans included limitations on the number of visits for a given problem, the type of provider who could offer them, and limitations on which drugs or tests could be offered for free. Others offered broader benefits, they reported in the Centers for Disease Control and Prevention's weekly report on disease and death. 

 

“Although [the task force] provides clinical guidance on how to implement recommendations within health care provider practices, it does not define the recommendations in language that can be applied readily to the delivery of health insurance benefits,” Jillian Jacobellis and colleagues at the Colorado Department of Public Health and Environment wrote. They advise that the “recommendations should be translated clearly into health-benefit language.”

The research has clear implications for national requirements that insurers cover an identical set of services without charging patients' copays. It also may inform regulation on broader rules on all the services health insurers must offer patients.

On Friday, the independent Institute of Medicine is scheduled to release guidelines on the minimum services a health insurance company will need to offer to be eligible for entry into state insurance exchanges. The final determination of these “essential health benefits” will be key in determining the content and cost of health insurance plans around the country.

It is unclear whether regulators will opt to describe specific required benefits or will instead use vaguer language that outlines broad categories of care that must be covered in some fashion. The Colorado study suggests the second approach could lead to wide variation in benefit designs meant to comply with the rules.

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