Health insurance is complicated. Whether it’s finding a doctor included in your network, understanding what everything costs, or finding out what’s covered, making sense of your coverage is known to cause a few headaches—just trying to make sense of the basics such as deductible, network, and coinsurance.
Added to this is the challenge of understanding what is covered and what isn’t in your insurance. But that’s not the only level of complexity—because once you get a grasp of the overarching requirements, you have to see what your state needs in addition to this. Following or look into essential health benefits on the federal level, we would today like to share with you a bit of information on how to make sense of benefits at the state level.
Background: Federal Essential Health Benefits
Last year, we introduced our readers to the idea of Essential Health Benefits—the ten necessary services that an insurer needs to cover in order to be listed on the Federal Marketplace.
“During the creation and passage of the Affordable Care Act, policymakers determined ten “essential health benefits,” designed to make sure individual and small group health insurance plans offered a quorum of services to be considered federally recognized.
Though not all plans (i.e. short-term insurance) offer this, if a plan is to be Healthcare.gov certified and delivered through the marketplace, a plan must cover [ten services deemed necessary].”
Summary of Federally Mandated Essential Health Benefits
Included in the list of services are the following:
- Ambulatory patient services: Care provided without entering a hospital.
- Preventive and wellness services; chronic disease management: Annual checkups, screenings, and immunizations, etc.
- Emergency services: Hospital care, to be provided in-network regardless of status.
- Hospitalization: Surgery, overnight stays, etc.
- Pregnancy, maternity, and newborn care: Services provided before and after your child is born.
- Mental health and substance abuse: Behavioral health treatment, inpatient services, and substance use disorder.
- Prescription drugs: At least one drug in every category and class of the United States Pharmacopeia. Learn more about prescription drug formularies and tiers here.
- Rehabilitative and habilitative services and devices: Services and devices to help people with injuries, disabilities, or chronic conditions.
- Laboratory services: Blood tests, x-rays, preventive screenings.
- Pediatric services: Dental and vision for children under 19.
Federalism vs. Federally Mandated
However, in this, we noted that the term “essential” means a variety of things, highlighting that residents of each state have different needs, different cost tolerances, and different challenges. Understandably, much like the different approaches to running a health insurance marketplace, different states deem various services essential.
Initial Passage
This came as a result of a 2013 announcement from the Department of Health and Human Services (HHS) issued to keep marketplace-purchased plans aligned with the offerings available to local residents receiving coverage through an employer plan. In this, HHS allowed states to select their own benchmark plans, choosing from the following benchmarks:
- One of the three largest plans, by enrollment, in the state’s small-group market;
- One of the state’s three largest state employee plans
- One of the three largest Federal Employees Health Benefit Program options;
- The state’s largest non-Medicaid HMO.
Increased Flexibility in 2020 and Beyond
However, in an effort to free up insurance companies to provide cost-effective health coverage, CMS made changes to increase flexibility in plan years 2020 and beyond. Written to prevent state benefits from becoming more generous than comparable plans and help residents save money, this was the closest scenario to opening up insurance across state lines. In turn, states were able to choose one of the following:
- Option 1:Selecting the EHB-benchmark plan that another State used for the 2017 plan year.
- Option 2:Replacing one or more categories of EHBs under its EHB-benchmark plan used for the 2017 plan year with the same category or categories of EHB from the EHB-benchmark plan that another State used for the 2017 plan year.
- Option 3:Otherwise selecting a set of benefits that would become the State’s EHB-benchmark plan.
For a current, consolidated list of the EHB-benchmark plans for the 50 states, click here. For more information on how states can select different sets of EHBs under the 2018 notice, click here.
State-by-State Required Benefits
Depending on the laws passed pertaining to essential benefits, states require a variety services in addition to the 10 Federally mandated ones. Additionally, states may cover different benefits differently and take a different approach to coverage. As noted in the CMS page on Essential Health Benefits,
“For purposes of determining EHB, State-required benefits (or mandates) are considered to include only requirements to cover specific care, treatment, or services.
Provider mandates that require reimbursement of specific health care professionals who render a covered service within their scope of practice are not considered to be State-required benefits for purposes of EHB coverage.
Similarly, State-required benefits are not considered to include dependent mandates, which require defining dependents in a specific manner or covering dependents under certain circumstances (e.g., newborn coverage, adopted children, domestic partners, and disabled children). Finally, State anti-discrimination requirements relating to service delivery method (e.g., telemedicine) are not considered to be State-required benefits.”
Alabama
- Benchmark Plan: Blue Cross and Blue Shield of Alabama – 320 Plan
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision
- Required Benefits: State-required benefits
Alaska
- Benchmark Plan: Premera Blue Cross Blue Shield of Alaska – Heritage Select Envoy
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision
- Required Benefits: State-required benefits
Arizona
- Benchmark Plan: The State of Arizona EPO Employee Health Plan
- Plan Type: State Employee Plan
- Supplemented Categories: Pediatric Dental, Pediatric Vision, Habilitation services
- Required Benefits: State-required benefits
Arkansas
- Benchmark Plan: HMO Partners, Inc. – Small Group Gold 1000-1
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental
- Required Benefits: State-required benefits
California
- Benchmark Plan: Kaiser Foundation Health Plan Inc. – Small Group HMO 30
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision
- Required Benefits: State-required benefits
Colorado
- Benchmark Plan: Colorado State LG A230 State Employee Health Plan
- Plan Type: State Employee Plan
- Supplemented Categories: Pediatric Dental
- Required Benefits: State-required benefits
Connecticut
- Benchmark Plan: ConnectiCare Insurance Company, Inc. – Connecticare Flex POS plan
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits
Delaware
- Benchmark Plan: Highmark BCBSD Inc. – Small Group Shared Cost EPO $2000/100 Plan
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits
District of Columbia
- Benchmark Plan: GHMSI – Blue Preferred PPO $1,000 – 100%/80%
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits
Florida
- Benchmark Plan: Blue Cross and Blue Shield of Florida – BlueOptions 5462
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision, Habilitation services
- Required Benefits: State-required benefits
Georgia
- Benchmark Plan: Humana Employers Health Plan of Georgia, Inc. – Copay Option 22
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits
Hawaii
- Benchmark Plan: Hawaii Medical Service Association – Preferred Provider Plan 2010
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision, Habilitation Services (Federal Definition)
- Required Benefits: State-required benefits
Idaho
- Benchmark Plan: Blue Cross of Idaho Health Service, Inc. – Preferred Blue PPO Small Group
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision
- Required Benefits: State-required benefits
Illinois
- Benchmark Plan: Blue Cross Blue Shield of Illinois – Blue PPO Gold 011
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision
- Required Benefits: State-required benefits
Indiana
- Benchmark Plan: Anthem Ins Companies Inc – Blue 6.0 Blue Access PPO Option 14, Rx G
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision
- Required Benefits: State-required benefits
Iowa
- Benchmark Plan: Wellmark Inc. – CompleteBlue 2000
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental
- Required Benefits: State-required benefits
Kansas
- Benchmark Plan: Blue Cross and Blue Shield of Kansas, Inc. – Blue Choice Comprehensive Major Medical
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision, Habilitation Services (Federal Definition)
- Required Benefits: State-required benefits
Kentucky
- Benchmark Plan: UnitedHealthcare of Kentucky, Ltd. – Choice Plus
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits
Louisiana
- Benchmark Plan: Louisiana Health Service & Indemnity Company – GroupCare Copay 80/60 $1000
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision, Habilitation Services (Federal Definition)
- Required Benefits: State-required benefits (PDF)
Maine
- Benchmark Plan: Anthem Health Plans of Maine (Anthem BCBS) – Blue Choice, $30.00, $2,500 Ded
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision
- Required Benefits: State-required benefits
Maryland
- Benchmark Plan: CareFirst BlueChoice, Inc. – BlueChoice HMO HSA-HRA $1,500
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits
Massachusetts
- Benchmark Plan: Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. – HMO Blue New England $2000 Deductible
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision
- Required Benefits: State-required benefits
Michigan
- Benchmark Plan: PriorityHealth – PriorityHMO
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision
- Required Benefits: State-required benefits
Minnesota
- Benchmark Plan: HealthPartners, Inc. – HLPT-129123512
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental
- Required Benefits: State-required benefits
Mississippi
- Benchmark Plan: Blue Cross Blue Shield of Mississippi – Network Blue
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision, Habilitation Services (Federal Definition)
- Required Benefits: State-required benefits
Missouri
- Benchmark Plan: Healthy Alliance Life Co (Anthem BCBS) – PPO On Exchange
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental
- Required Benefits: State-required benefits
Montana
- Benchmark Plan: Blue Cross and Blue Shield of Montana – Blue Preferred Gold PPO 007
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental
- Required Benefits: State-required benefits
Nebraska
- Benchmark Plan: Blue Cross and Blue Shield of Nebraska – Blue Pride Plus Option 102 Gold
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits
Nevada
- Benchmark Plan: Health Plan of Nevada, Inc. – HPN Solutions HMO Platinum 15/0/90%
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits
New Hampshire
- Benchmark Plan: Anthem – Matthew Thornton Blue
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental
- Required Benefits: State-required benefits
New Jersey
- Benchmark Plan: Horizon Healthcare Services, Inc. – Advantage EPO Silver 100/50
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental
- Required Benefits: State-required benefits
New Mexico
- Benchmark Plan: Presbyterian Health Plan Inc. – Individual Silver C HMO
- Plan Type: State Non-Medicaid HMO
- Supplemented Categories: Pediatric Dental, Pediatric Vision, Habilitation Services (Federal Definition)
- Required Benefits: State-required benefits
New York
- Benchmark Plan: Oxford Health Insurance, Inc. – Oxford EPO
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits
North Carolina
- Benchmark Plan: Blue Cross and Blue Shield of North Carolina – Blue Options PPO
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision
- Required Benefits: State-required benefits
North Dakota
- Benchmark Plan: Blue Cross Blue Shield of North Dakota – BlueCare Gold 90 500
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits
Ohio
- Benchmark Plan: Community Insurance Company (Anthem BCBS) – Blue Access (PPO) – Standard Opt D55
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision, Habilitation and Rehabilitation (State Definition)
- Required Benefits: State-required benefits
Oklahoma
- Benchmark Plan: Blue Cross Blue Shield of Oklahoma – Blue Options Gold 002
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits
Oregon
- Benchmark Plan: PacificSource Health Plans – Preferred Codeduct Value 3000+35/70% 0812 Tiered Value Rx 10/50/75 0812
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision
- Required Benefits: State-required benefits
Pennsylvania
- Benchmark Plan: Keystone Health Plan East, Inc. – Gold Premier HMO
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits
Rhode Island
- Benchmark Plan: Blue Cross Blue Shield of Rhode Island – VantageBlue 100/60 1500/3000 RX 3/12/35/60/100 WOPD
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental
- Required Benefits: State-required benefits
South Carolina
- Benchmark Plan: Blue Cross and Blue Shield of South Carolina – Business Blue Complete
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision, Habilitation (federally defined)
- Required Benefits: State-required benefits
South Dakota
- Benchmark Plan: Wellmark of South Dakota – Blue Select Primary PCP/NonPCP Copay Plan
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision
- Required Benefits: State-required benefits
Tennessee
- Benchmark Plan: BlueCross BlueShield of Tennessee – SG Gold 13S
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits
Texas
- Benchmark Plan: Blue Cross Blue Shield of Texas – Blue Choice PPO RSH3
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision
- Required Benefits: State-required benefits
Utah
- Benchmark Plan: Public Employees Health Program (PEHP) Utah Basic Plus Plan
- Plan Type: State Employee Plan
- Supplemented Categories: Habilitation services (state definition)
- Required Benefits: State-required benefits (PDF)
Vermont
- Benchmark Plan: The Vermont Health Plan, LLC – Silver CDHP Plan
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits
Virginia
- Benchmark Plan: Anthem Health Plans of VA (Anthem BCBS) – Premier DirectAccess PPO
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental
- Required Benefits: State-required benefits
Washington
- Benchmark Plan: Regence BlueShield – Regence Direct Gold +
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: Benefits health plans must cover under Washington state law
West Virginia
- Benchmark Plan: Highmark Blue Cross Blue Shield West Virginia – Gold Shared Cost PPO $1000
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State-required benefits in West Virginia
Wisconsin
- Benchmark Plan: UnitedHealthcare Insurance Company – Choice Plus
- Plan Type: Small Group Market
- Supplemented Categories: Pediatric Dental, Pediatric Vision, Habilitation services
- Required Benefits: State-required benefits in Wisconsin
Wyoming
- Benchmark Plan: Blue Cross Blue Shield of Wyoming – BlueSelect Silver for Employer Groups
- Plan Type: Small Group Market
- Supplemented Categories: None
- Required Benefits: State Required Benefits in Wyoming
The Complicated Network of Health Insurance Doesn’t Have to Be This Complicated
One of the hardest parts about offering access to health insurance for more than 300 million Americans spread across 50 states is that each locality is different. Residents of each state have different needs, different cost tolerances, and different challenges, making a one-size-fits-all program impossible.
This means that Essential Health Benefits mean a lot of different things to a lot of different people. On one hand, it allows a state to tailor the required services to its population; on the other, it creates a vast difference in cost structures, risk pools, and the like for every state. While a state like Illinois may require insurers to cover bariatric surgery or hearing aids, head across the border to Indiana and neither is required.
Even a decade after the Affordable Care Act was passed, finding health insurance is still one of those things that is a mystery for many Americans. If you’re looking for help understanding your options, Insurance Broker Hub can help.
Our free service gives you access to an independent network of national brokers who have the experience and expertise to design a plan around your needs and budget. Ready to get started? Simply request a no obligation health insurance quote here.
