The federal Patient Protection and Affordable Care Act (PPACA) requires health plans that offer insurance coverage in the individual and small group markets to ensure that such coverage includes the essential health benefits package (EHB) for plan years beginning on and after January 1, 2014. PPACA (1) directs the U.S. Department of Health and Human Services (HHS) secretary to define the EHB and (2) requires the EHB to include 10 specific benefit categories.
On December 16, 2011, HHS published a bulletin to provide information and solicit comments on the regulatory approach the department plans to propose for defining the EHB. HHS’ intended regulatory approach relies on states identifying a reference (benchmark) plan based on employer-sponsored coverage available in the marketplace today, supplemented as necessary to ensure that the plan covers the 10 statutory categories of benefits. Thus, HHS proposes that each state select a benchmark plan that will serve as the EHB in that state. HHS suggests the following four benchmark plan types, from which each state will select one:
- the largest plan by enrollment in any of the three largest small group insurance products in the state’s small group market,
- any of the three largest state employee health benefit plans by enrollment,
- any of the three largest national Federal Employees Health Benefit Program plan options by enrollment, or
- the largest insured commercial non-Medicaid health maintenance organization operating in the state.
If a state does not select one of these, the largest plan in the state’s small group market becomes the default benchmark plan, according to HHS.
For an overview of PPACA, see OLR Report 2010-R-0255. For more information on essential health benefits, see OLR Report 2012-R-0022.
