The Affordable Care Act (ACA)established a minimum set defines a set of health services that must be covered by all new insurance plans in the State Insurance Exchanges starting in 2014, called the Essential Health Benefits (EHBs).  

The EHBs include services within the following 10 categories:

- Ambulatory patient services

- Emergency services

- Hospitalization

- Maternity and newborn care

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

- Prescription drugs

- Rehabilitative and habilitative services and devices

- Laboratory services

- Preventive and wellness services

- Pediatric services, including oral and vision care

State Determination

Defining exactly which items in these categories would be covered was left up to the Secretary of Health and Human Services (HHS).

HHS took the approach of giving each state the authority to set a “benchmark” for delivering the EHBs, based on one of 10 options:

- one of the three largest small group plans in the state
- one of the three largest state employee health plans
- one of the three largest federal employee health plan options
- the largest HMO plan offered in the state’s commercial market


The benchmark selected by each state will determine the minimum baseline of benefits for all of the new plans available to individuals and small groups within the State Insurance Exchanges after 2014. However, the EHB package that is selected by the state will still have to comply with all non-discrimination requirements under the law.

States are currently moving forward with selecting their benchmark plans. This process holds many potential ramifications for HIV patients. The options available to lawmakers in each state differ widely, and it is almost certain that the choices will lead to vastly different plans and options from state-to-state.

Learn more about the Essential Health Benefits:

Essential Health Benefits - HIV Health Reform

Webinar on the Essential Health Benefits and HIV

Get involved in your state:

Advocate’s Toolkit to Help Shape Your State’s Essential Health Benefit Plan – 6/26/12

Defining the Essential Health Benefits in Your State – July 2012