The 10 essential health benefits as defined by the Patient Protection and Affordable Care Act were viewed by the Obama administration as, well, essential. But the controversial list included coverage of many procedures and treatments that had formerly been only partially covered or not covered at all. In addition to objections raised by some based upon a religious belief, concerns were raised by others, including state agencies, about their ability to quickly shift to the EHB format.
The feds conceded that a transition period would be appropriate. As a result, states were given the option to select a set of EHBs in an already existing plan. Their choices:
- One of the three largest plans, by enrollment, in the state’s small-group market;
- One of the state’s three largest state employee plans;
- One of the three largest Federal Employees Health Benefit Program options;
- The state’s largest non-Medicaid HMO.
A new report funded by the Robert Wood Johnson Foundation discovered “significant state variation in the essential health benefit packages” from state to state.
“State mandates [of benefits to be included in basic coverage plans] rarely reflect systematic decisions about the value and effectiveness of a particular service,” the report noted. “The ACA was supposed to change that. It required that new plans sold on the individual market or to small groups include a package of “essential health benefits (EHBs)” that covered 10 broad categories. … For both political and practical reasons, DHHS chose to allow states to define their own EHBs in 2014 and 2015 by picking an existing benefits package offered by one of a number of “benchmark plans” in the state.”
What emerged was a hodgepodge of state plans.
“Twenty-five states defaulted to the largest small-group plan in the state; 20 states and DC chose one of the small-group plans; two states chose a state employee plan; and three chose the largest HMO. None chose a federal employee plan,” the study found. “It is not surprising that 45 of 50 states hazve a small-group benchmark. Choosing a federal plan could have exposed the state to extra costs if a state-mandated benefit were not in the plan; alternatively, the federal plan could have included benefits not generally available in the state’s individual or small-group market. By choosing a benchmark plan to included state-mandated benefits, a state could avoid financial exposure.”
Among the details uncovered by the study:
- 25 states require plans to cover nutrition counseling
- 26 states require coverage of services to treat autism
- 45 states require coverage of chiropractic care
- 5 require coverage for weight loss programs
“The report illustrates that outside of the 10 ACA-mandated service categories, where patients live determines whether they’ll have coverage for the care they need. For example, only 25 states require plans to cover nutrition counseling, and 26 states require coverage of services to treat autism. Forty-five states require coverage of chiropractic care, while only five require coverage for weight loss programs. Furthermore, even if states offer services, states impose different annual or episodic limits on the amount of coverage,” the researchers wrote. “The government will reassess whether or not to set a national benchmark EHB plan in 2016, but until then, the range and scope of services included in the EHBs will vary greatly from state to state.”
