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Vorys Health Care Advisors

States Begin to Choose Essential Health Benefits for Their Citizens

Posted in Health Care Reform, Medicaid

Although not a “hard” deadline, states were encouraged to submit to the federal government by Monday, October 1, 2012, their lists of essential health benefits required by the Affordable Care Act (ACA).  Essential health benefits are a set of health care service categories that must be covered by certain plans beginning in 2014.  According to the Health Affairs Blog, as of October 3, 2012, 20 states plus the District of Columbia have made at least a preliminary decision about the minimum set of benefits to which millions of their residents will be entitled.

Essential health benefit requirements apply to individual and small group plans sold inside and outside of Health Insurance Exchanges.  Health Insurance Exchanges are mechanisms provided for in the ACA that will allow individuals to purchase affordable health insurance.  They are scheduled to launch in January 2014.  The requirements also apply to benefits provided to individuals who will be newly eligible for Medicaid coverage provided as part of the ACA’s Medicaid expansion.  Essential health benefit requirements do not apply to self-insured health plans, the method by which most large companies cover their employees.

According to Kaiser Health News, “The health law lists 10 broad categories of essential benefits, including preventive care, emergency services, maternity care, hospital and doctors’ services, and prescription drugs.  States have latitude within those categories, and so far nearly all have selected as a benchmark for minimum coverage one of the three most popular small group health plans available to residents now.  Because these plans vary and states can tinker with specific benefits to comply with federal requirements, the minimum benefits available to consumers in California will be different from those for people in New York, for example.”

State Refor(u)m provides additional information regarding the benchmark plans states have chosen.  For example, Arizona has selected as its benchmark plan the state employee plan, while New York has decided on a small group plan.  Some states, like North Carolina, have not yet chosen a plan.  Ohio and several other states—including Alabama, Florida, Iowa, Indiana, Louisiana, New  Jersey, Oklahoma, Pennsylvania, Tennessee, Wisconsin, and West Virginia—have indicated that they are awaiting additional federal guidance before making a selection.

On December 16, 2011, the Department of Health and Human Services (HHS) issued a bulletin providing information and soliciting comments on the regulatory approach that HHS proposed to define essential health benefits under the ACA.  HHS has not yet issued final guidance regarding essential health benefits, and is not expected to do so until after the November election