Analyzing the affordable care act: essential health benefits and implications for oncology

The Patient Protection and Affordable Care Act (ACA) will have lasting effects on oncology coverage and, perhaps, on oncology practice as well. The ACA ushers in a new class of insured individuals; approximately 25 million will purchase insurance through the exchanges, and Medicaid will expand by 12 million beneficiaries over the next 10 years. Essential health benefits (EHBs), which are required in all qualified health plans (QHPs) sold in the exchanges, will define the coverage available to the newly insured population and could lead to the development of new definitions and standards for medical necessity. This article will discuss effects of the ACA EHB requirements on oncology coverage, as well as the state and federal options and responsibilities as they relate to coverage of and access to oncology services within the QHPs in the exchanges.