The Affordable Care Act ("ACA" and also frequently referred to as "Obamacare") requires health plans to cover certain categories of benefits. These categories are described as "essential health benefits." Beginning in 2014 individual and small group plans will have to include essential health benefits unless the plan qualifies as grandfathered.
Section 1302 of the Affordable Care Act requires health plans to provide coverage for at least the following categories:
Ambulatory patient services - These include outpatient services such as doctor visits.
Emergency services - These include care received in an Emergency Room
Hospitalization - These include medically-necessary surgeries and other inpatient procedures
Maternity and newborn care
Mental health services
Substance use disorder services – These services include behavioral health treatment
Prescription drug coverage
Rehabilitative and habilitative services and devices - Rehabilitation covers services such as relearning to walk after a stroke. Habilitative services involve learning a new skill such as a speaking without a speech impediment.
Laboratory tests and services
Preventive and wellness services as well as the management of chronic diseases
Pediatric services (including both oral care and vision care)
Health plans are allowed to impose cost sharing obligations on plan members for most essential benefits, but those that qualify under a category of preventative health services will be made available at no charge to plan members.
The ACA gives states authority to specify details surrounding the essential benefits. The states must each choose a benchmark plan that will serve as a more detailed definition of benefits within each of the ten Essential Health Benefit categories. Below is a list of the Essential Health Benefits benchmark plan for each state. Additional information on the benchmark plans can be found on the government’s CCIIO web site.
Alabama – "Blue Cross Blue Shield of Alabama - 320 Plan"
Alaska – "Premera Blue Cross Blue Shield of Alaska - Heritage Select Envoy"
Arizona – "State of Arizona Self-Insured Plan, administered by United Healthcare - Arizona Benefit Options EPO Plan"
Arkansas – "HMO Partners, Inc. - Open Access POS, 13262AR001"
California – "Kaiser Foundation Health Plan, Inc. - Kaiser Foundation Health Plan Small Group HMO 30 ID 40513CA035"
Colorado – "Kaiser Foundation Health Plan of Colorado - Ded HMO 1200D"
Connecticut - "Connecticare, Inc. - Connecticare HMO"
Delaware – "Blue Cross Blue Shield of Delaware - Simply Blue EPO 100 500"
D.C. – "Group Hospitalization and Medical Services, Inc. - BluePreferred PPO Option 1"
Florida – "Blue Cross and Blue Shield of Florida - BlueOptions 5462"
Georgia – "BCBS Healthcare Plan of Georgia, Inc. - HMO Urgent Care 60 Copay"
Hawaii – "Hawaii Medical Service Association - HMSA Preferred Provider Plan 2010"
Idaho – "Blue Cross of Idaho Health Service Inc. - Preferred Blue"
Illinois – "Blue Cross Blue Shield of Illinois - BlueCross BlueShield of Illinois BlueAdvantage"
Indiana – "Anthem Ins Companies Inc (Anthem BCBS) - Blue 5 Blue Access PPO Medical Option 6 Rx Option G"
Iowa – "Wellmark Inc. - Copyament Plus"
Kansas – "Blue Cross and Blue Shield of Kansas - Comprehensive Major Medical Blue Choice GF 500 Deductible with Blue Rx card"
Kentucky - "Anthem Health Plans of KY (Anthem BCBS) - Anthem PPO"
Louisiana – "Blue Cross and Blue Shield of Louisiana - GroupCare PPO"
Maine - "Anthem Health Plans of ME (Anthem BCBS) - Blue Choice 20 with Rx 10 30 50 50"
Maryland – "CareFirst BlueChoice, Inc. - Blue Choice HMO HSA Open Access"
Massachusetts – "Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. - HMO Blue 2000 Deductible"
Michigan – "Priority Health - 100 Percent Hospital Services Plan"
Minnesota – "HealthPartners, Inc. - 500 25 Open Access"
Mississippi – "Blue Cross & Blue Shield of Mississippi - Network Blue"
Missouri – "Healthy Alliance Life Co (Anthem BCBS) - Blue 5 Blue"
Montana – "Blue Cross and Blue Shield of Montana - Blue Dimensions"
Nebraska – "Blue Cross and Blue Shield of Nebraska - Blue Pride"
Nevada – "Health Plan of Nevada, Inc. - Health Plan of Nevada Point Of Service Group 1 C XV 500 HCR"
New Hampshire - "Matthew Thornton Health Plan (Anthem BCBS) -Matthew Thornton Blue Health Plan"
New Jersey – "Horizon HMO - Horizon HMO Access HSA Compatible"• New Mexico – "Lovelace Insurance Company - Lovelace Classic PPO"
New York – "Horizon HMO - Horizon HMO Access HSA Compatible"
North Carolina – "Blue Cross and Blue Shield of NC - Blue Options"
North Dakota – "Sanford Health Plan - Sanford Health Plan HMO"
Ohio – "Community Insurance Company (Anthem BCBS) - Blue 6 Blue Access PPO Medical Option D4 Rx Option G"
Oklahoma – "Blue Cross Blue Shield of Oklahoma - RYB05"
Oregon – "PacificSource Health Plans - Preferred CoDeduct Value 3000 35 70"
Pennsylvania – "Aetna Health Inc. - PA POS Cost Sharing 34 1500 Ded"
Rhode Island – "Blue Cross & Blue Shield of Rhode Island - Vantage Blue BCBSRI"
South Carolina – "BlueCross BlueShield of South Carolina - Business Blue Complete"
South Dakota – "Wellmark of South Dakota - Blue Select"
Tennessee – "BlueCross BlueShield of Tennessee - BCBST PPO"
Texas – "Blue Cross Blue Shield of Texas - RS26"
Utah – "Public Employee’s Health Program - Utah Basic Plus"
Vermont – "The Vermont Health Plan, LLC - BlueCare, The Vermont Health Plan, LLC, CDHP"
Virginia – "Anthem Health Plans of VA (Anthem BCBS) - KeyCare 30 with KC30 Rx Plan 10 30 50 OR 20"
Washington – "Regence BlueShield - Regence Blue Shield nongrandfathered small group product"
West Virginia – "Highmark Blue Cross Blue Shield West Virginia - Super Blue Plus 2000 1000 Ded"
Wisconsin – "UnitedHealthcare Insurance Company - Choice Plus Definity HSA Plan A92NS"
Wyoming – "Blue Cross Blue Shield of Wyoming - Blue Choice Business 1000 80 20"
Will Essential Health Benefit Requirements Affect My Coverage?
Health plans have a good idea regarding the types of coverage that the ACA considers to be essential, but significant details remain to be worked out. These definitions will impact many people, since an estimated 68 million consumers are expected to obtain a health plan covered by essential health benefit rules.
The insurance industry has warned that the essential health benefit requirement will add to the cost of providing individual and small employer health coverage. For example, currently over sixty percent of individual market plan members do not have coverage for maternity services and nearly twenty percent have no mental health coverage. Starting in 2014 plans would have to include those benefits in order to make them available for sale.
How HealthPocket Can Help
The essential benefit requirement is one of the ACA features that will create market improvements with the offsetting challenge of containing cost of the new requirements. Having standard coverage categories may make it easier for consumers to compare choices among the available plans within a specific state.
The delicate balance between benefits, cost and quality will be the primary focus of HealthPocket as implementation of the ACA builds momentum in 2013. The changes coming make it crucial for plan consumers to be aware of a plan’s benefit structure and costs as well as its ability to provide the highest level of quality possible. Each consumer’s health situation and needs will greatly influence which plan choice makes the most sense for her or him.