The Affordable Care Act (ACA) established a minimum set of health services that must be covered by all Qualified Health Plans sold in the State Insurance Exchanges called the Essential Health Benefits (EHBs).
The EHBs include services within the following 10 categories:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services
- Pediatric services, including oral and vision care
The Essential Health Benefits also apply to the Medicaid Expansion, in a different way. There will be a standard Medicaid benefit package for newly eligible beneficiaries that will include the same list of “essential health benefits.” The federal government will broadly define which benefits must be covered and states will have the option to add more.
Defining exactly which items in these categories would be covered was left up to the Secretary of Health and Human Services (HHS). Instead of setting a national standard for what must be covered, HHS gave the states considerable ability to define the EHBs.
HHS gave each state the authority to select a “benchmark” plan on which to base the minimum baseline of benefits for all of the new plans available to individuals and small groups within the State Insurance Exchanges after 2014. The benchmark had to be based on one of 10 options:
- 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
All plans sold in the Exchanges must meet a minimum standard of the same level and scope of coverage in the benchmark plan. However, the details of the benefits covered within each category will vary. The EHB package that was selected by the state still must comply with all non-discrimination requirements under the law.
Learn more: Health Reform in My State
EHBs in Medicaid:
In states that take up the Medicaid Expansion, newly covered Medicaid beneficiaries will receive an “Alternative Benefits Package” (ABP) that includes the EHBs.
The ABP will be determined by the states, and may be modeled after the state’s chosen benchmark plan for the Insurance Exchange, or the state’s traditional Medicaid benefits package. However, the ABP will be measured against the benchmark plan for adequacy.
New Medicaid patients that are determined to be “medically frail” will have the option of enrolling in the traditional Medicaid benefits package, or the ABP.
Patients with HIV, hepatitis, and other chronic conditions will likely fall under the “medically frail” definition. This will give them the option of choosing the more comprehensive coverage option of the two.
HHS determined that both the private insurance plans in the Exchanges and new Medicaid patients in states that offer Medicaid Expansion will have the same requirement for prescription drug coverage in the EHBs.
The EHBs requirement for prescription drugs for both, is coverage of the greater of either:
- One drug in every category and class (as defined by the U.S. Pharmacopeia classification system); or
- The same number of drugs in each category and class as the state benchmark plan
Both the private insurance plans in the Exchanges and new Medicaid patients in under the Expansion are required to cover certain preventive services without cost-sharing.
- Preventive services with a United States Preventive Services Task Force (USPSTF) Grade A or B rating
- Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP), and
- Specified women’s preventive services as determined by the Secretary of HHS.
States may also choose to cover these services for traditional Medicaid patients, and will be eligible for a 1% increase in federal matching funds if they do so.
Learn more about what this means for HIV Testing Coverage.
Information on Proposed State Essential Health Benefits Benchmark Plans - The Center for Consumer Information & Insurance Oversight, CMS.gov
Health Reform Issue Brief: Essential Health Benefits - NASTAD
Essential Health Benefits - HIV Health Reform
Webinar on the Essential Health Benefits and HIV – HIV Health Reform.com
Health Reform Issue Brief: EHBs- NASTAD
Marketplace Health Plans Assessment Workbook and Worksheet- Center for Health Law and Policy Innovation at Harvard Law School
What the Medicaid EHBs Mean for HIV/AIDS Programs- NASTAD
Advocate’s Toolkit to Help Shape Your State’s Essential Health Benefit Plan – 6/26/12
Defining the Essential Health Benefits in Your State – July 2012