Moving to High Quality, Adequate Coverage: State Implementation of New Essential Health Benefit Requirements

Patients complete paperwork in a waiting room.

Beginning in January of 2014, insurance companies offering plans in the insurance exchanges created by the Affordable Care Act must adhere to regulations establishing ‘essential health benefits.’

This report looks at how insurance companies and state governments in various states are dealing with the new regulations and highlights the struggles and successes they have experienced to date.

Key Findings

  • Technical glitches and tight deadlines posed challenges for insurers and regulators alike, but an “all hands on deck” mentality and commitment to consumers have kept the process moving forward.

  • Officials in all but one of the states analyzed reported that they have had good communication with the federal government regarding plan management and oversight.

  • Insurers and regulators in most study states reported that the shift to an essential health benefit standard would cause minimal change or disruption, while in one state it would result in a significantly expanded set of benefits for individual policyholders.

  • Insurers are engaging in minimal substitution of covered benefits in the first year, meaning that plans will closely resemble the benefits, limits, and exclusions prescribed in the benchmark package, with differences primarily reflected in cost-sharing and network design.

  • One study state is facilitating consumers’ ability to make “apples-to-apples” plan comparisons by standardizing benefit designs inside and outside the exchange.

The report was funded by the Robert Wood Johnson Foundation as part of the ACA Implementation - Monitoring and Tracking series. It was prepared by researchers at the Urban Institute and Georgetown University’s Health Policy Institute–Center on Health Insurance Reforms.

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