Saturday, January 7, 2012

ACA Update: Essential Health Benefits and What They Mean for You

By Emily McKinley, Health Information Specialist

On December 16, 2011, the Department of Health and Human Services (HHS) issued a bulletin further defining Essential Health Benefits (EHB), a critical element of the Affordable Care Act (ACA). This provision of the act was initially designed and included in the legislation to ensure all Americans have affordable access to a comprehensive health care insurance policy.

Essential Health Benefits define the categories of care that must be covered by all certified and non-grandfathered insurance plans beginning in January of 2014. (Grandfathered plans include some group and individual plans created and sold on or before March 23, 2010. For more information about grandfathered plans, please visit

Ten benefit categories are considered EHB. Those are: ambulating patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitation and habilitative services and devices; laboratory services; preventative and wellness services and chronic disease management; and pediatric services, including oral and vision care. What was unclear upon the announcement of the legislation was how EHB would be further defined to provide comprehensive and relatively uniform care.

The December 16th bulletin released by HHS outlined a policy by which the States were granted considerable freedom in defining the scope of EHB while still setting regulatory “benchmarks” that each state must meet. According to the bulletin, in choosing the benchmark system, “HHS sought to balance comprehensiveness, affordability, and state flexibility and to reflect public input received to date.” Furthermore, HHS stated, “benefits must not be designed in ways that discriminate based on age, disability, or expected length of life, but must consider the health care needs of diverse segments of the population.”

The benchmarks that States may use to define the scope of EHB are based on one of four types of preexisting insurance plans. Those plans may be pulled from:

  • One of the three largest small group plans in the state;
  • One of the three largest state employee health plans;
  • One of the three largest federal employee health plan options;
  • The largest HMO plan offered in the state’s commercial market.

In many cases, States may find it necessary to supplement benchmark plans to include all EHB categories as well as any currently operating state mandates, such as Autism Mandates. In these cases, the States may choose to pull EHB definition and scope from a second benchmark option. In all cases, already enacted mandates will remain effective until 2016, at which point an HHS review will be completed.

HHS acknowledges sparse precedent among the benchmark plans for certain EHB categories, namely habilitative care and pediatric oral and vision care. There is concern and debate regarding the “advantages and disadvantages of including maintenance of function as part of the definition of habilitative care services.” HHS is specifically soliciting comment regarding these categories of EHB as well as benefit design flexibility with regard to benefit substitutions, and updating and assessing EHB.

As always, Family Voices Indiana encourages consumers to learn how EHB definitions may affect all aspects of the care your family may need and to comment appropriately to HHS. Without federal regulation of EHB, states may vary widely in the scope of coverage offered for the various benefits, which could significantly impact consumers’ coverage and the true comprehensiveness of the ACA. While the bulletin does outline the manner in which States will define coverage for EHB, many questions remain, such as the true scope of each EHB category as well as the breadth and frequency of services offered within those categories. Furthermore, consumers residing in states not governed by diagnosis- and treatment-specific mandates may suffer from cuts to existing comprehensive and quality insurance policies.

While EHB must be offered by insurance programs, the bulletin addresses only the scope of benefit definitions. That is to say, EHB cost sharing between the insurer and consumer are not specifically regulated by the ACA. Therefore, deductibles, premiums, and co-pays relating to EHB may vary.

Public comment on these and all topics regarding EHB may be made via email to Comments must be submitted before January 31, 2012.

To read the bulletin in its entirety, please visit:

For additional information about the bulletin and to access fact sheets regarding EHB coverage and plan comparisons, please visit:

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