EHB "Pre-rule" Leaves ACA Benchmark Plan to States

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EHB "Pre-rule" Leaves ACA Benchmark Plan to States

December 19, 2011

The Department of Health and Human Services released a new bulletin Friday on the essential health benefits package (EHB) as part of the implementation of the Affordable Care Act. In this “pre-rule,” HHS says that it intends to propose that the ACA’s essential health benefits be defined by a benchmark plan selected by each state. Serving as a reference to plan the scope of services and coverage limits, the benchmark will be selected by each state.

States need to develop the essential benefit packages as part of their work to establish online insurance marketplaces, called exchanges, set to open in 2014.In addition, states need to know the scope of the coverage because they must pay the cost of any medical services their laws mandate that go beyond the essential benefits called for in the federal law.

The four EHB benchmark plan options outlined by HHS are:

  1. One of the three largest small group plans in the state;

  2. One of the three largest state employee health plans;

  3. One of the three largest federal employee health plan options; and

  4. The largest HMO plan offered in the state’s commercial market.

If a state doesn't choose one of those options, the default benchmark would be the state's largest small group market plan based on enrollment.

ANCOR is a part of a national “HabCoalition” that has worked with HHS to insure that the EHB includes habilitiation. While the pre-rule does outline that habilitation benefits must have parity with rehabilitation, HHS is still gathering data regarding coverage of habilitation in insurance plans.

What does this mean for ANCOR members? At this time, with the flexibility offered to states, ANCOR members should listen carefully to their state’s approach to establishing their EHB benchmark and join discussions to advocate for coverage of habilitation and other services provided as part of Medicaid. This is important because coverage of habilitation by the state’s EHB would result in another funding stream for ANCOR members, should they decide to approach the market covered by the EHB.

Watch WICs for more information as this is developing.