US states are being given more freedom and flexibility in the implementation of health reform as stipulated in the Affordable Care Act, which aims to make sure all US citizens have access to affordable, quality health insurance, according to a bulletin released by the HHS (Department of Health and Human Services).

In order to achieve cover for everybody, the law aims to ensure that health insurance plans on offer have a comprehensive package of services and items, which the HHS refers to as “essential health benefits”. In today’s HHS bulletin, there is a proposal that explains to stakeholders how it plans to define essential health benefits.

In a communiqué, the HHS wrote:

“HHS is releasing this intended approach to give consumers, states, employers and issuers timely information as they work toward establishing Exchanges and making decisions for 2014. This approach was developed with significant input from the public, as well as reports from the Department of Labor, the Institute of Medicine, and research conducted by HHS.”

HHS Secretary, Kathleen Sebelius, said:

“Under the Affordable Care Act, consumers and small businesses can be confident that the insurance plans they choose and purchase will cover a comprehensive and affordable set of health services. Our approach will protect consumers and give states the flexibility to design coverage options that meet their unique needs.”

The HHS proposes that individual states have the freedom and flexibility to choose an existing health plan to set the standard for the services and items, to be the necessary components of an essential health benefits package.

The following health insurance plans would be chosen as a benchmark:

One out of the three largest group plans that exist in the state

One out of the three largest state employee health plans that exist in the state

The biggest HMO plan available in the commercial market of that state

The individual state would then be able to include the benefits and services from the health insurance plan it had selected, to devise the essential health benefits package.

As long as the total value of a coverage was not undermined or reduced, plans within a benefit category could be modified.

The states have to make sure the essential health benefits package covers services and items in at least ten categories, including:

Ambulatory patient services

Emergency services

Hospitalization

Laboratory services

Maternity and newborn care

Mental health and substance use disorder services, including behavioral health treatment

Pediatric services, including oral and vision care

Prescription drugs

Preventive and wellness services and chronic disease management

Rehabilitative and habilitative services and devices

If a chosen plan does not cover all the ten categories, it will be able to look at other benchmark insurance plans to determine which benefits to include in the package – including the Federal Employee Health Benefits Plan.

This proposal allows states to choose a plan that would match the services covered by a typical employer plan available in each state. Insurers and states would have the flexibility to develop the benefits package so that they would eventually meet citizens’ needs.

Sherry Glied, PhD, assistant secretary for planning and evaluation, said:

“More than 30 million Americans who newly have insurance coverage in 2014 will have a comprehensive benefit package. In addition to assuring comprehensive coverage for the newly insured, many millions of Americans buying their own insurance today will gain valuable new coverage, including more than 8 million Americans who currently do not have maternity coverage, and more than 1 million who will gain prescription drug coverage.”

The proposal in today’s bulletin does not address cost sharing, coinsurance, copayments or deductibles, but rather only the services and items a health plan might cover. The other features will be addressed in future bulletins, the HHS says.

Members of the public are invited to send their proposals to EssentialHealthBenefits@cms.hhs.gov by January 31st, 2012.

Written by Christian Nordqvist