Where do States Stand on Affordable Care Act’s Essential Health Benefits?

By Joe Touschner

As shocking as it may seem, the end of the year is less than 90 days away.  That’s right, we’re in the fourth quarter, the one that includes Halloween, Thanksgiving, the holiday season, and New Year’s Eve.  The third quarter wrapped up at the end of September, and with it the time frame that HHS suggested in its EHB guidance that states would have to select a benchmark plan.

Does that mean we know the essential health benefits for each state?  Not yet.  While many states have moved to select benchmark plans, others are taking advantage of the flexibility HHS has provided and have yet to make a choice.  And remember that selecting a benchmark plan is one step in setting the essential health benefits—some benchmark plans need to be supplemented to fulfill the Affordable Care Act’s standards.  You might further recall that the ACA gave the Secretary of HHS—not the states—the authority to set the EHBs. We expect HHS to formally propose rules that recognize states’ choices or implement the default option that the Department has outlined.

So given all that, where do we stand?  Twenty-four states and DC have chosen or made a recommendation on a benchmark plan and many have also identified supplementary benefits. Most have chosen a small group market plan as the benchmark, with a few selecting HMOs or a state employee plan.

As Say Ahhh! readers likely know, one of the categories the ACA requires to be covered is “pediatric services, including oral and vision care”. We think that clearly means children should receive the full range of services they need, including oral, vision, and other types of services.  But the guidance from HHS so far has only emphasized the oral and vision aspects of this category, so to the extent states have supplemented their benchmark plans’ pediatric services, they have covered only oral and vision.  Twelve states have identified or recommended their state’s CHIP dental benefit package as the pediatric oral health benefit benchmark.  At least one (Rhode Island) has recommended the federal employees dental benefit package as the kids dental benefit.  For vision services, some states have identified the federal employees plan, while others have pointed to their CHIP vision benefits, even though this was not explicitly mentioned as an option in federal guidance.

Dedicated EHB watchers can check out State Refor(u)m’s collection of state choices and recommendations.  Another valuable resource for state advocates comes from the Child and Family Policy Center in Iowa.  CPFC has identified eight questions advocates should ask about essential health benefits for children; the questions emphasize getting children the full spectrum of services they need to grow and develop to their fullest potential.

The process of setting the essential health benefits continues—more states may act to make choices and we expect federal rules to make the selections official before the year is fully out.  Stay tuned for more on this process and how it impacts kids and their families.