By Sumita Saxena, Senior Consultant, The Verden Group
The federal government is allowing states to choose a different essential health benefits (EHB) benchmark plan for 2017. According to LifeHealthPro, this might result in further public debate about what types of services health insurance should cover in plans sold pursuant to the Affordable Care Act (ACA).
Benchmark plans must cover at least 10 general categories of essential healthcare items and services to mirror the scope of benefits available through a typical employer-sponsored insurance plan. The controversy surrounding these services stems from the fact that the healthcare reform law enables states to interpret what belongs in the 10 categories of essential benefits. For example, though benefits requirements include preventative services, different insurer interpretations of this provision have resulted in confusion and disparity as to what exactly must be covered.
In 2011, CMS asked states and the District of Columbia to select an EHB benchmark plan voluntarily. Benchmark plans can evolve from a number of different categories: they can be one of the three largest small group plans in the state; any of the three largest plans offered to state workers; any of the three largest Federal Employees Health Benefits Program products; or a state’s largest, fully insured commercial HMO plan, as noted by LifeHealthPro.
For the 2017 plan year, CMS has made it administratively simpler for states to choose an EHB benchmark plan, according to an agency statement. Instead of creating a new reporting obligation with a separate form to complete, states can send CMS an email with the plan’s data form filing previously submitted to the state regulator. CMS estimates that states can fulfill this requirement in about 30 minutes.
When 25 states declined to choose a benchmark plan in 2011, CMS selected the plan for them. The default benchmark plan is the largest plan by enrollment in the largest product by enrollment in the state’s small group market segment.
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