By Joe Touschner
Who remembers the essential health benefits? It was more than two years ago when JoAnn Volk filled us in on the plans states were choosing as their benchmarks to help set the minimum benefits in individual and small group market plans. More recently, Wakely Consulting offered a very helpful comparison of benefits under EHBs and under CHIP—it showed some concerning shortcomings in pediatric services, which the ACA requires to be part of the EHBs. Now, two new briefs give us even more information about how states have shaped the benefits for small businesses and those who buy coverage on their own—including everyone who buys plans through marketplaces.
The first new resource comes from JoAnn’s colleagues at Georgetown’s Center for Health Insurance Reforms. It looks not at the EHBs themselves, but the rules states have established around them. In a brief for the Commonwealth Fund, CHIR experts detail which nine states prohibit insurers from making substitutions within the EHBs; which states selected a benchmark that covered habilitative services or adopted a state-wide definition for those services; and which took steps to further regulate how EHB pediatric dental services are provided.
The second new EHB brief, this one from the Leonard Davis Institute of Health Economics at the University of Pennsylvania, examines how state benchmark plans cover eleven different benefits. Included are some key benefits for children such as hearing aids and treatments for autism spectrum disorders—in both of those cases, only about half of states have made the benefit part of the EHBs.
These reports and others have made it clear that giving states the opportunity to set EHBs based on plans that were offered back in 2012 has led to significant variation across states. Benefits considered “essential” in one part of the country may not be in another. And it seems that even though the ACA mandates the inclusion of pediatric services, treatments that some kids need, like hearing aids, are not part of the package in many states.
When families start to sign up for 2015 marketplace plans this month, they are likely to find benefits similar to those offered this year. That’s because HHS’s approach to EHBs applies to plan years 2014 and 2015. But the department promised a review of that approach for plan year 2016. At CCF, we want to see a review that will address the shortcomings of EHBs in pediatric services and other areas. But indications are that the scope of HHS’s review will be limited. Advocates for kids and others need to speak up now to encourage HHS to do a thorough review of the EHBs and fill the holes that prevent some people from getting the comprehensive coverage they expect from ACA-compliant plans.
