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Report: Wide Variation in States’ Essential Health Benefits

October 22, 2014

new report finds significant state variation in the essential health benefit packages (EHBs) that insurance companies are required to cover if they offer plans in the marketplaces created by the Affordable Care Act (ACA). The report, prepared by researchers at the University of Pennsylvania’s Leonard Davis Institute and funded by the Robert Wood Johnson Foundation, details what each state requires of its marketplace plans and how the requirements were shaped.

The report illustrates that outside of the 10 ACA-mandated service categories, where patients live determines whether they’ll have coverage for the care they need. For example, only 25 states require plans to cover nutrition counseling, and 26 states require coverage of services to treat autism. Forty-five states require coverage of chiropractic care, while only five require coverage for weight loss programs. Furthermore, even if states offer services, states impose different annual or episodic limits on the amount of coverage.

The authors note that the variation in state EHB requirements mostly comes from what states required of insurance plans prior to the ACA and states’ ability to individually select their own benchmark plan when shaping marketplace EHBs. The government will reassess whether or not to set a national benchmark plan in 2016, but until then, the range and scope of services included in EHBs will vary greatly from state to state.

“Although marketplace plans have to cover the 10 ACA-mandated essential health benefits, there is still significant state variation,” said Katherine Hempstead, who directs coverage issues at the Robert Wood Johnson Foundation. “Essential Health Benefits are defined by states and based on state benchmarks, and while they cover the 10 categories, they also reflect the legacy of state insurance mandates and state differences in the definition of what is essential.”

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