Advocates Eyeing ACA `Essential Health Benefit’ Requirements for 2016

The plan for designating benefits that must be covered by most health plans in the individual and small group markets is set to expire at the end of 2015, so advocacy groups are starting to push for what they want to see the Department of Health and Human Services issue for plan years starting in 2016.

At an annual conference Jan. 23 sponsored by Families USA, which strongly supports the Affordable Care Act, speakers said the HHS should set minimum standards for the ACA “essential health benefits” (EHBs) -- 10 broad categories of health care services that must be covered by plans that took effect after the law was enacted in 2010 – including plans sold within as well as outside of the ACA marketplaces.

“Every state should be required to adopt a uniform definition as a minimum unless the state’s definition is more comprehensive,” said Michelle Lilienfeld, senior attorney in the Los Angeles office of the National Health Law Program. The uniform minimum definition should be set by the HHS, she said.

Under a final rule issued by the HHS in 2013, states can choose from a list of options to designate “benchmark” plans on which EHBs are based. In most states small group plans are the benchmark models. But Lilienfeld said that doesn’t work for such categories as pediatric services. Small group plans typically “were created with adults in mind,” she said.

In November 2014 the HHS published a proposed rule for EHBs in 2016. The proposal generally would allow states to continue choosing benchmark plans, but they could update their benchmarks for 2017 with ACA-compliant plans from 2014.

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