It is now official. The federal government is not going to define a specific, uniform, set of essential health benefits that health insurers all across the nation would have to provide. Instead, it will be up to each individual state to decide upon those benefits for their citizens.
Part of the Affordable Care Act requires that each state create their own health insurance exchange. Those that choose not to will still have an insurance exchange. In those cases, the federal government will set up one for them, within their state.
The purpose of these exchanges is to make it easier for Americans to understand what they are getting, (as well as what they aren’t getting), when they purchase health insurance. It is supposed to be an “apples to apples” type of comparison. In order for a health insurer to be allowed to sell policies in the insurance exchange, the insurer would have to offer at least a minimum of essential health benefits.
There has been concern about exactly who would get to make the decision about what the essential health benefits would be. Many Republicans have expressed the opinion that if the federal government, (in other words, the Obama Administration), made that decision that it would create a very rigid, bureaucrat-controlled health system. They also said that a “one-size-fits-all” approach would threaten the quality of care that Americans would receive.
Instead, it has become official that individual states will be allowed to make their own decisions about what essential health benefits they want to have health insurers be required to offer. This would give each state more flexibility and freedom to tailor things to better fit the needs of the people in their states.
This means that each state can match the benefits of specific health insurance plans that are currently being offered to the people who live in that state. The state can choose to match one of these groups:
The three smallest group plans in the state (based on enrollment)
The three largest health plans that are available to state employees
The three largest health plans that are available to federal workers
The largest HMO offered in that state’s commercial market
States would not be allowed to decide to include health insurance plans that do not offer at least the minimum health benefits. All plans must be equal to the scope of benefits that are provided by a typical employer sponsored health insurance plan. It also has to include “habilitative services” for people who have autism or cerebral palsy.
Sometime in 2012, the Supreme Court will decide if the individual mandate, (the law that requires everyone to buy health insurance in 2014), is, or is not, constitutional. Depending on how that goes, the decisions about the essential health benefits could, potentially, change.
Image by Kate Ter Haar on Flickr