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- What's essential in some states isn't in others, study finds
By Bob Herman4 pm, Oct. 21 |
President Barack Obama's healthcare law mandated that certain health plans start covering common services. But because the federal government offered states latitude in those initial determinations, the definition of an essential health benefit ranges widely across the country, a report finds.
For example, a person with an Obamacare plan in Illinois can receive coverage for nutrition counseling, hearing aids and infertility treatments. However, someone in neighboring Indiana doesn't have any of those in his or her standard plan.
The Patient Protection and Affordable Care Act requires plans sold in the individual and small-group markets to cover 10 essential health benefits, from emergency room services to hospitalization to prescription drugs. However, in 2013, HHS finalized a rule that said for the time being, states have the ability to define essential health benefits by picking an existing package already offered by a health plan in the state.
University of Pennsylvania researchers found in the Robert Wood Johnson Foundation report that beyond the 10 required coverage areas, other common health benefits such as chiropractic care and bariatric surgery varied significantly by state. Overall, 88% of states required plans to pay for chiropractic care, but only 10% of states mandate the same for acupuncture and weight-loss programs.
The variation exists because many states defaulted to their own health plans that already have state-mandated benefits. If states chose a more costly benchmark plan that did not include state-mandated coverage, they would be on the hook for the added costs. Instead, defaulting to the simplest option that met state and federal requirements avoided financial, and political, pushback.
“Essential health benefits are defined by states and based on state benchmarks, and while they cover the 10 (ACA-mandated) categories, they also reflect the legacy of state insurance mandates and state differences in the definition of what is essential,” Katherine Hempstead, a health insurance policy director at the Robert Wood Johnson Foundation, said in a statement.
HHS still needs to issue essential health benefit guidance for 2016 plans and beyond. Businesses and health insurers have lobbied the government to keep covered benefits reasonable to avoid high premiums.
Follow Bob Herman on Twitter: @MHbherman