When approving Qualified Health Plans (QHPs) for operation on the new Marketplaces, states and the US Department of Health and Human Services (HHS) must ensure that a QHP’s coverage decisions, reimbursement rates, incentive programs, and benefit design avoids discrimination against individuals because of, among other things, disability. In addition, health benefits established as essential cannot be subject to denial to individuals against their wishes on the basis of an individual’s present or predicted disability, degree of medical dependency or quality of life.
Non-discrimination provisions under the Affordable Care Act (ACA), as well as guidance from HHS, dictate that states should ensure that plans are not arbitrarily restricting certain essential benefits, or covering them in a manner that is not balanced across the categories of covered benefits. States must ensure that limitations imposed on certain benefits do not violate the non-discrimination provisions of the ACA by failing to accommodate the health care and functional needs of persons with disabling diagnoses or conditions.
States must also take care that QHPs not discriminate against persons with certain conditions by limiting or omitting coverage for certain treatments that are only relevant to people with that particular condition. For example, failing to include coverage of cochlear implants and post-procedure therapy services would discriminate against people with hearing loss. States must develop process protections to ensure that they fully examine the final EHB package that they adopt. Additionally they must ensure that the QHPs they certify conform to the letter and spirit of the Affordable Care Act.
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