disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care (P.L. 111-148, Sec. 1302 [42 U.S.C. 18022]). HHS decided to allow each state the flexibility to select a plan from several options to serve as the benchmark for the essential health benefits package in that state.11 Services covered by the benchmark plan in each of the 10 mandated areas become the essential benefits for plans in that state (Cassidy, 2012).
Health plans within and outside of the health insurance exchanges, except grandfathered plans, must provide, at a minimum, coverage for the essential benefits package of at least 60 percent of the actuarial value of the covered benefits, with limits on annual cost sharing (KFF, 2011a). Medicaid programs within states that implement the expansion provision of the ACA also must provide benefits comparable to those in the essential health benefits package to newly eligible adults (KFF, 2011a).
As of 2010, the ACA improves preventive care coverage by eliminating cost sharing within Medicare for preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) (i.e., services rated A or B) and requiring health plans to provide the same services without cost sharing, as well as recommended immunizations, pediatric and adolescent preventive care, and preventive care and screenings for women (KFF, 2011a). The ACA also offers incentives to states in which Medicaid covers USPTF A- and B-rated services and recommended immunizations without cost sharing (KFF, 2011a).
Although the ACA establishes federal mandates and standards regarding health insurance, states are among those entities responsible for implementing some of the most significant changes, such as establishment of state health insurance exchanges and whether to accept the Medicaid expansion provision.12Box 2-1 lists some of areas in which state variation in implementation of the ACA is anticipated.
11States may choose as their benchmark “one of the three largest small group plans in the state by enrollment, one of the three largest state employee health plans by enrollment, one of the three largest federal employee health plan options by enrollment, or the largest health maintenance organization (HMO) plan offered in the state’s commercial market by enrollment” (Cassidy, 2012).
12Most of the consumer protection and insurance reform provisions of the ACA apply to the U.S. territories as well as states and the District of Columbia, although there are some differences (NASTAD, 2012a). People residing in the territories are exempt from the individual mandate, and the territories are not required to establish health insurance exchanges, although