Yes, you heard it right – it’s time to do essential health benefits selection…again.

Recently, my colleague Emily Polk blogged about an upcoming opportunity for states to select a new essential health benefits (EHB) benchmark. She touched on the importance of advocacy as states contemplate selecting a new benchmark and go through the process of supplementing that benchmark to best meet the health needs of consumers. The time to act is, well…now.

Why is EHB selection important?

The EHB benchmark is the core set of benefits that serve as the base plan for qualified health plans (QHPs) sold in the Marketplaces. These benefits are included in all QHPs and all new plans in the small and nongroup markets. While the ACA outlines 10 benefit categories that the benchmark must cover, states have discretion as to whether the benchmark’s benefits fulfill the intent of the law. We know this imperfect process leads to wide variation in EHB benchmarks across the country. By way of example, Massachusetts’ benchmark included a pediatric vision benefit in their EHB selection; therefore, Massachusetts did not supplement their benchmark with a more robust option. The Massachusetts plan does not include eyeglasses for children. It is troubling that a child in Ohio may access eyeglasses after a failed vision exam while a child in Massachusetts cannot.

What are the implications of a new benchmark?

There are a number of areas where the EHB falls short for consumers. These range from the limited inclusion of mental health/behavioral health and substance use disorder services to pediatrics services and habilitative services. This is not surprising given some states’ lack of enthusiasm for selecting the EHB in 2013. This time around, as in 2013, if a state does not select a benchmark for 2017 from the 2014 list of the three largest small group products by state, they will default to the largest small group plan.

In 2013, 26 states defaulted to the largest small group plan, refusing to engage in the EHB process.

How can this time be different?

This time around, advocates and stakeholders are more familiar with the process of selection and the challenges with the EHB. If you need a refresher, check out this overview. Advocates must take this opportunity to amplify consumers’ concerns with the current EHB and communicate consumer stories to key decision makers. In a transparent process, the state will need to listen to consumers’ needs and consider selecting a new benchmark plan and supplement plans to address any shortcomings that exist.

In early April, The Center for Consumer Information and Insurance Oversight (CCIIO) published a list of the three largest small group plans by state, signaling to states that their preliminary EHB selection process should commence. Now is the time for state agencies, consumer advocates and other key stakeholders to come to the table and work together to make sure that the next generation of EHB benchmarks is better than the last.