The future health insurance exchange under the Affordable Care Act will need to offer an Essential Benefit Package. In fact, most health insurance plans will need to cover each state’s Essential Benefit Package starting New Year’s Day in 2014. There are 10 key service categories that future plans will need to cover- including behavioral health services.
States need to pick a plan from a set of existing options as their “benchmark” plan- which will serve as the state-specific essential benefit package. The options to choose from include: 1) the largest plan by enrollment in any of the three largest small group insurance products in the small group market; 2) any of the largest three state employee health benefit plans by enrollment; 3) any of the largest three national federal employees health plans; or 4) the largest insured commercial non-Medicaid HMO in the State. If the benchmark plan doesn’t include all the 10 key service categories then it needs to be supplemented.
The due date for states to pick a benchmark plan is September 30 of this year. If a state doesn’t want to pick a benchmark plan, the Fed’s will make the choice for them- and they intend to choose “… the largest small group market product in the State’s small group market” which (in Arizona) is Aetna’s PPO plan. Once a state picks the benchmark plan (or has it picked for them)- it becomes a “reference plan” for the state for a couple of years- meaning that future exchange health plans must be “substantially equal” to the benchmark plan in the scope, limitations and exclusions (e.g. visit limits).
Obviously there’s a lot more to it than that… and you or your Stakeholders can get a lot more in-depth info about what an Essential Health Benefit is and what it means in this document that provides an Arizona specific analysis of the issues and the various services that are covered by potential benchmark plans.