Essential Health Benefits: A Child’s Perspective

As soon as rumors started flying about what would be in the essential health benefits guidelines I thought hmmmm that sounds a lot like CHIP. At first blush the new guidance does sound like the CHIP model – indeed the guidance says as much (p. 8). But as HHS officials and others have pointed out, there are ways in which this new guidance is quite different from CHIP.

As my colleague Joe Touschner blogged about before Christmas, states will now have a choice of choosing from a number of benchmarks that mirror the choices in CHIP i.e. an FEHBP equivalent product, a state employee package or coverage offered through the largest commercial HMO. The Essential Health Benefits (EHB) guidance specifies that any of the three largest state or federal employees plans by enrollment would be acceptable.

But the EHB guidance offers a new option – the three largest plans (by enrollment) in a state’s small group market. This option has caused some concern since coverage in the small group market is generally not as good as on the large employer side.

According to the guidance, small group coverage is actually very similar to large group coverage – and indeed all of the listed benchmarks according to the guidance (p. 4) – in terms of benefits covered.  Where significant differences may occur it would be more likely to be in the area of cost-sharing – and the EHB guidance does not address the issue of cost-sharing.

We hope that HHS officials will share the data they have on this important question since there are many reasons why states may wind up choosing a small group package as its benchmark. (More on this in a later blog.) And finding out what the top 3 plans are in your state is top of the 2012 to do list for many state readers I suspect. But for now back to the CHIP analogy….

Of course one obvious difference is that the CHIP program allows states to choose to do a Medicaid expansion or a separate state program with a benchmark package. For kids, this means that they have access to the Medicaid EPSDT benefit – which according to the Academy of Pediatrics is the gold standard for kids — if the state goes the Medicaid route. For EHB, states don’t have the option of going the EPSDT route for kids.

Another way in which the EHB guidance is different from CHIP is that the Affordable Care Act included a list of 10 benefits that must be covered. This list includes “pediatric services, including oral and vision care” – so these benefits will need to be added if not covered by the benchmark package. The list of benefit categories may constrain some of the flexibility in the benchmark options that states have in CHIP. On the other hand the EHB guidance may offer more flexibility than the CHIP standard in some respects — another topic for a future day – what kind of insurer flexibility is really floating around in the EHB guidance?

Finally, unlike CHIP, the ACA includes anti-discrimination provisions with respect to age, disability and expected length of life.

So lots to think about as we all work to prepare comments on the federal proposal AND as states start to think about their choice of benefits package. As with much else in the implementation of the ACA, state action will be critical here. Stay tuned!

Editor’s Note:  This is the first in a series of forthcoming blogs focusing on essential health benefits from the perspective of children and families.  We welcome guest bloggers to submit entries on this topic.  Please contact Say Ahhh! editor Cathy Hope if you would like to submit a blog.

Joan Alker
Joan Alker is the Executive Director of the Center for Children and Families