7. ESSENTIAL HEALTH BENEFITS
The ACA instituted new rules that require all plans in the individual market as well as Medicaid expansion programs to cover ten categories of benefits. Of particular importance to women has been the inclusion of maternity care, preventive services, and mental health.
The ACA requires all Marketplace plans and Medicaid expansion programs to cover ten categories of “essential health benefits” (EHB). Each state chooses a benchmark benefit plan, which sets the floor for services that plans in that state must cover within each EHB category.15
ACA Required Essential Health Benefits |
|
Prior to the ACA, there were few federal requirements on what private plans in the individual market had to cover. The ACA established a floor for benefits that individual market plans must cover with the goal of reducing variation and adverse selection by standardizing “meaningful coverage.” This is particularly important for women, as they are the exclusive users of maternity care and more frequent users of services in some other EHB categories, such as prescription drugs and mental health. Mental health services in particular were routinely excluded in individual plans prior to the ACA. Depression, anxiety, and eating disorders are all more common among women than men.
The AHCA would allow states to apply for a waiver to define their own EHBs beginning in 2020. Waivers would be automatically approved unless the HHS Secretary issues a denial within 60 days of submission. This means states could choose to exclude mental health or maternity care (see pregnancy-related care section below) from their EHB requirements. While the idea of choice sounds appealing to some, it is antithetical to how insurance operates ─ by spreading the costs and risks across the pool of insured individuals. Plans that include a broader range of benefits would be considerably more expensive than they are today. In addition to state-level waivers, the AHCA bill would rescind the EHB requirement for Medicaid expansion programs, meaning that beneficiaries in this group would not be entitled to coverage for all ten categories. Existing Medicaid rules require states to cover some of the categories, such as hospitalization and maternity and newborn care, but others such as substance abuse treatment and prescription drugs are optional and offered at state discretion.
Back to top
More Articles
- Kaiser Health News*: May 11th Era of ‘Free’ Covid Vaccines, Test Kits, and Treatments Is Ending. Who Will Pay the Tab Now?
- Continuous Challenges: Dr. Anthony Fauci Reflects On the Perpetual Challenge of Infectious Diseases
- Kaiser Health News: In Some States, Voters Will Get to Decide the Future of Abortion Rights
- Attorney General Merrick B. Garland Statement on Supreme Court Ruling in Dobbs v. Jackson Women’s Health Organization
- Stateline, Biden Likely to Help States Increase Health Care Access: December 15, 2020, Last Day to Enroll In or Change Plans for 2021 Coverage and GAO Reports on Breast and Cervical Cancer.
- Kaiser Health Foundation: Distributing a COVID-19 Vaccine Across the U.S. - A Look at Key Issues
- Women's Congressional Weekly Legislative Update: Paycheck Protection Program Restrictions, Child Care Grants, Pandemic Unemployment Assistance
- Hollowed-Out Public Health System Faces More Cuts Amid Virus; "When we do our job, nothing happens"
- Bills Introduced, May 11 - 15: To Provide Emergency Assistance to Families Through Home Visiting Programs; Modifying Restaurant Meals Program under SNAP; Emergency Grants to States & Indian Tribes
- Kaiser Family Foundation: Eligibility for ACA Health Coverage Following Job Loss; What Is ESI?