Benefits ‘Essential’ In N.J. But Not In Pa.

Every “qualified” health insurance plan sold on the Affordable Care Act individual or small business marketplaces must include 10 essential health benefits.

They are mandated by the law, and cover everything from emergency services and hospitalizations to maternity care and prescription drugs.

But there’s one little rub: Each state has a surprising amount of leeway to define what is essential. And benefits in Pennsylvania are a lot stingier than in New Jersey.

“Pennsylvania is one of the states that doesn’t do well,” says Janet Weiner, associate director of health policy at the Leonard Davis Institute at the University of Pennsylvania.

In a study published last week with the Robert Wood Johnson Foundation, Weiner and colleague Christopher Colameco laid out how “essential” benefits can vary.

Bariatric surgery is essential in 23 states (45 percent) but only five (10 percent) cover weight-loss programs.

Chiropractic visits are essential in 45 states (88 percent); only five states (10 percent) pay for acupuncture.

In Pennsylvania, chiropractic care is the only practice identified from a list of 11 condition-specific services. Hop over to New Jersey, and chiropractic care along with six other condition-specific services are covered.

A similar pattern holds for infertility care, Weiner said. It’s essential in New Jersey, not in Pennsylvania.

Getting a standard every state would accept was the Department of Health and Human Services’ job. But as the days ticked down to last year’s marketplace launch, the agency decided to punt.

Weiner says that was probably wise. Trying to establish a new standard in the run-up to the ACA “would have been quite bloody.” That’s because state-mandated benefits often follow long battles among various advocacy groups and politicians.

Instead, HHS opted to let each state define its own essentials for the first two years. Last year and again this year, states can choose from 10 benchmark plans: One of the three largest federal employee plans; the state’s largest non-Medicaid HMO; one of the three largest small-group plans; or one of the three largest state employee plans.

“This was a reasonable alternative because it allowed HHS to take advantage of plans that were already enforced in the states and already had existing pricing,” she says.

Pennsylvania defaulted to its largest small-group policy, Aetna’s Point of Service plan. New Jersey picked a Horizon HMO small-group plan.

HHS is set to announce an interim policy in 2016. But after gazing into her crystal ball, Weiner doesn’t see that happening. “The same battles and the same difficulties would appear to them in 2016, which is not that far away,” she says. “So I wouldn’t be surprised if this interim policy continues.”

So really, how much of a game changer are the 10 essential benefits if the same limits that existed pre-ACA remain? Weiner says they have added services such as maternity care and preventive care that weren’t routinely available before.

She also understands why someone in Pennsylvania needing hearing aids, which are not covered, would be upset that across the river those same hearing aids are deemed essential benefits.

“These are real issues for people needing these services,” she says. “You don’t have to have a lot of inside-baseball knowledge to understand the issue.”

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Insurance States The Health Law