Essential Health Benefits and the Affordable Care Act: Law and Process

Abstract

Starting in 2014, the Affordable Care Act (ACA) will require private insurance plans sold in the individual and small-group markets to cover a roster of “essential health benefits.” Precisely which benefits should count as essential, however, was left to the discretion of the Department of Health and Human Services (HHS). The matter was both important and controversial. Nonetheless, HHS announced its policy by posting on the Internet a thirteen-page bulletin stating that it would allow each state to define essential benefits for itself. On both substance and procedure, the move was surprising. The state-by-state approach departed from the uniform, federal standard that the ACA appears to anticipate and that informed observers expected HHS to adopt. And announcing the policy through an Internet bulletin appeared to allow HHS to sidestep traditional administrative procedures, including notice and comment, immediate review in the courts, and White House oversight. This article explores two questions. First, is the state-by-state approach a lawful exercise of HHS's authority? Second, did HHS in fact evade the procedural obligations that are meant to shape the exercise of its discretion?

Are You Covered? Associations Between Patient Protection and Affordable Care Act Knowledge and Preventive Reproductive Service Use

“…Essential Health Benefits are benefits that health insurance plans sold through the state marketplaces, individual and small-group plans sold outside of the marketplaces, and Medicaid plans are required to cover as of January 2014. 29 This questionnaire contained 10 knowledge questions, which asked whether certain provisions related to the Essential Health Benefits associated with women’s preventive reproductive health care are included as part of the health-care law or not, with response options of “true” and “false.” Using the Flesch-Kincaid reading grade-level test, the questionnaire items were determined to be at a 12th-grade reading level. Further, based on the model of Gross and colleagues, 27 following each knowledge item, participants were asked to indicate their level of certainty that their response was correct on a 1 (not sure at all) to 5 (extremely sure) scale.…”

What should health insurance cover? A comparison of Israeli and US approaches to benefit design under national health reform

“…Although HHS’ ultimate approach to implementation surprised many but made basic sense given the confusion of the legislative language itself, the political and constitutional tensions, and the need for a pragmatic solution that could move the nation toward full implementation of a benefit design affecting nearly 70 million people (Bagley and Levy, 2014).…”

The Affordable Care Act and assisted reproductive technology use

“…For various reasons-some pragmatic, some political-the ACA's framers left the specific formulation of benefits offered within EHB categories to the states. 13 Despite some regional and state-to-state variation, the ACA's most important effect on benefits occurs in ten areas where the bill rationalizes benefits across individual medical insurance plans (see Table 1), both to ensure that consumers purchase and are enrolled in plans that meet most health needs that the Institute of Medicine (IOM) has deemed essential and to create broad insurance ''pools'' that spread risk across as many insureds as possible.…”