OLR Report 2012-R-0022 gives information on the “essential health benefits package” required by the 2010 federal health care reform act, including recent guidance from the U.S. Department of Health and Human Services (HHS) on certain benchmark plans. It also explains if the state's mandated insurance benefits will be included in the benefit package.
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 HHS secretary to define the EHB and (2) requires the EHB to include 10 specific benefit categories. (For an overview of PPACA, see OLR Report 2010-R-0255.)
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:
1. the largest plan by enrollment in any of the three largest small group insurance products in the state's small group market,
2. any of the three largest state employee health benefit plans by enrollment,
3. any of the three largest national Federal Employees Health Benefit Program (FEHBP) plan options by enrollment, or
4. the largest insured commercial non-Medicaid health maintenance organization (HMO) 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.
Depending on the plan selected as a benchmark, current state mandated insurance benefits (e.g., mammograms, autism spectrum disorders, etc.) may be considered part of the EHB. We discuss this in more detail below. (For a list of state mandated health insurance benefits, see OLR Report 2011-R-0504.)
We have identified the largest state employee health plans and national FEHBP plan options, as described below. We are unable to determine the largest small group plan or HMO in the state at this time. The Connecticut Health Insurance Exchange Board of Directors has proposed establishing a multi-agency task force to identify, compare, and contrast the four benchmark plans that may be chosen as the EHB for Connecticut. According to the board's proposal, the task force would likely include the Health Insurance Exchange, Connecticut Insurance Department, Health Care Advocate, executive and legislative leaders, and key stakeholders. According to the Insurance Department, it has offered to help the Exchange gather the necessary information from insurance carriers to inform the board's work.
