Report Finds Essential Health Benefits Vary From State to State
While all plans sold through the Affordable Care Act's health insurance exchanges must cover a set of essential health benefits, the definition of those benefits varies significantly from state to state, according to a new report from the Robert Wood Johnson Foundation, Modern Healthcare's "Vital Signs" reports (Herman, "Vital Signs," Modern Healthcare, 10/21).
Health insurers that participate in the ACA's exchanges must offer plans that include 10 EHBs:
- Ambulatory patient services;
- Emergency services;
- Maternity and newborn care;
- Mental health and substance use disorder services;
- Prescription drugs;
- Rehabilitative and habilitative services and devices;
- Laboratory services;
- Preventive and wellness services and chronic disease management; and
- Pediatric services.
However, instead of defining a national benefits package, HHS allowed each state to select its benchmark plan from a set of plans in their state. The benefits included in the benchmark plan are considered the EHBs for plans sold through the exchange in that state.
The benchmark plans used in each state include:
- The largest plan in the small-group market, which 25 states defaulted to;
- One of the three largest plans in the small-group market, which 20 states -- including California -- and Washington, D.C. selected;
- One of the state's three largest state employee health plans, which two states selected; and
- The state's largest non-Medicaid HMO, which three states selected (RWJF report, October 2014).
As a result, wide discrepancies exist between various states' benefits.
Different State, Different EHBs
For the RWFJ report, researchers at the University of Pennsylvania examined the EHB packages required in each state and found that:
- 45 states include chiropractic care;
- 26 include autism spectrum disorder services, like applied behavior analysis (Pradhan, Politico Pro, 10/21);
- 26 include hearing aids;
- 25 include nutrition counseling;
- 23 include bariatric weight loss surgery;
- 20 include routine foot care
- 19 include infertility treatments;
- Five include weight-loss services; and
- Five include acupuncture.
Specifically, California's EHB plan includes:
- Autism spectrum disorder services;
- Bariatric weight loss surgery; and
- Jaw joint, or TMJ, treatment (RWJF report, October 2014).
According to study co-author Janet Weiner, the "arbitrary" coverage decisions reflect the political issues and priorities for each state. In many states, providers and patients fought to get certain services to be labeled "mandatory," while employers and insurers often opposed designations that could raise costs.
Bloomberg Businessweek reports that insurance companies have little incentive to offer benefits that are not required because it encourages "adverse selection." If just one insurer covers a particular benefit, all the individuals who need that benefit will choose that plan.
While HHS will continue the "state-by-state" approach next year, federal health officials could recalibrate in 2016. Weiner said doing so "could be a messy battle" (Tozzi, Bloomberg Businessweek, 10/22).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.