It has been a long road for essential health benefits (EHBs); a set of health care services that must be included in all plans sold through state Marketplaces. With open enrollment just around the corner, it is important to revisit what standard benefits will be included in the packages and what to look out for. So let’s check in on where we’ve been, what’s happening now, and what we can do throughout open enrollment and in the coming year to ensure quality.

How did we get here?

As we blogged about back in February, instead of choosing one federal EHB, the Center for Consumer Information and Insurance Oversight (CCIIO) outlined a process for states to elect their own state-specific packages. States were given the choice of several existing state and federal plans, and if states did not select a plan, they defaulted to the largest small-group plan.

Implementation of EHB standards means some current plans will change significantly in 2014. Arecent study demonstrated that less than 2 percent of the current health plans as they exist now in the individual market meet EHB standards. Illustrating this, a recent New York Times articlefeatured a couple whose insurance did not cover maternity costs and were forced to pay out of pocket when they decided to have a child, leaving them to navigate a complicated menu of options with variable prices and questionable value. Only one-third of current health plans offer coverage for prenatal, delivery and postnatal care. Dental and vision care for children are the least likely benefits to be covered by health insurance plans sold on the individual market. Coverage for substance use disorders is not comprehensive and mental health treatments vary in the services insurers will cover. These inadequacies play out every day for American health care consumers. Standardizing the benefits offered in health insurance packages will prevent consumers from experiencing these large coverage gaps.

Where Are We Now?

If the plans selected as the state’s benchmark plan fell short in one of the EHB areas, states were supposed to supplement benefits to make sure they hit all required coverage areas. To this end, every state except Utah has added pediatric services such as vision, dental, or both. Only two states have added mental health and substance abuse services to their package (Alaska and Arkansas), whereas most states will be using the potentially weaker benefits already included in their benchmark plans. Habilitative services, such as occupational, physical, or speech therapies that help individuals gain, maintain, or improve daily functioning, are an area of concern sincemost states have left the definition of this category to the insurance companies.

By now, Qualified Health Plans (QHPs) have been approved by either state insurance departments (in states retaining plan management functions), or by CCIIO. As part of this review, regulators were supposed to ensure that in small group and individual markets, plans cover all 10 benefit areas of the EHB. CMS offers a list of state EHBs, and see this report for a more in-depth breakdown of state plan selections. It is up to state departments of insurance to make sure EHBs reflect the intent of the ACA and consumers receive the benefits that were promised.

Where Are We Headed?

The plan approval process is coming to an end, meaning benefit standards are set for the foreseeable future. Thus, it is now important to make sure review processes resulted in comprehensive, value-based plans. As health plans roll out, it is a good time to remind your state insurance department of their responsibilities to consumers and the important role processing consumer complaints will play in ensuring EHB delivers adequate and affordable coverage for everyone.

In working with your partners, highlight the relevant benefit areas EHB improves upon. For example, if you partner with a women’s organization, emphasize the importance of EHB coverage of maternity and key women’s preventive services. If you work with condition-specific groups, underscore the effect of nondiscrimination on the basis of preexisting conditions. If you work directly with consumers, remind them of the robust package of health care services that EHB delivers.

After certification, plans cannot be amended until 2015, thus monitoring strategies will play a central role in long-term advocacy work. This means looking out for stories of both gaps in coverage that may harm consumers and ways the ACA and EHBs are improving coverage. Particular areas of concern are habilitative servicespediatric dental servicesmaternal and women’s health services, and nondiscrimination for LGBTQ people. Stay tuned for more specific tools in these areas.

Consumer advocates share the end goal of ensuring the delivery of quality, robust, and comprehensive EHBs. Our work in the short-term involves unpacking that broader goal into short-term strategies: where are the action areas involving potential EHB weaknesses? Which stakeholders should advocates partner with to build consensus and coalitions? At Community Catalyst, identifying actionable strategies is the focus of our present work and we will be here to support you in the process of developing state-specific plans in the coming months.

 – Sarah Gordon, Private Insurance Intern