State Health Insurance Mandates and the PPACA Essential Benefits Provisions

Updated: February 20, 2013

Every state has a substantial number of laws that require private market health insurance to cover specific benefits and provider services. An introduction to such laws is provided below, titled, Understanding Mandated Health Insurance Benefits.

State Mandated Benefits: Traditionally states counted mandate laws to include required categories of "persons covered" (such as adopted children, handicapped dependents or adult dependents). With these laws, there are more than 1,900 such statutes among all 50 states; another analysis tallies more than 2,200 individual statute provisions, adopted over a 30+ year period. 

Federal "Essential Benefits: The Patient Protection and Affordable Care Act (PPACA) provides for "essential health benefits," defined as health treatment and services benefits and the right to use specialized provider services; these categories total about 1,600 to 1,800 as described in current (2011-2013) state laws. ^1,2

50-State Table of Proposed Essential Health Benefits Benchmarks On November 20, 2012 the Department of Health and Human Services (HHS) released proposed rules on essential health benefits, actuarial value and accreditation.   NCSL has compiled an easy-to-use 50-state table, including state selections and federal fall-backs, with links to details for each plan.

• 2011 and 2012 Enacted State Mandate Laws - NCSL has published a tally of new state mandate additions and changes, both related and unrelated to the PPACA, updated March 2012.
• CCIIO Release: Frequently Asked Questions (FAQs) on the Essential Health Benefits Bulletin
• NCSL Comments on the CMS Essential Health Benefits Bulletin
• Institute of Medicine benefits report, issued Oct. 6, 2011, can have a significant effect on future essential benefit definitions and state mandates. 
• Mandated Health Insurance Benefits and State Laws - NCSL web report with state mandate studies and evaluations, and NCSL specific mandate topic reports.

 

Federal Health Law and the Supreme Court On June 28, 2012, the Supreme Court issued an opinion upholding the Patient Protection and Affordable Care Act, with limitations on penalties for states that choose not to expand their Medicaid programs. The decision did not affect other provisions. The information on this web page continues to reflect state actions addressing the PPACA. For NCSL’s updated summary and analysis of the Court’s decision and its effects see: U.S. Supreme Court and Federal Health La

HHS Bulletins

On February 20, 2013 HHS issured a final rule on Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation.

On November 20, 2012 HHS issued new Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation.

On July 2, 2012 HHS issued Essential Health Benefits: List of the Largest Three Largest Small Group Products by State - providing updated details on the options for benchmark plans.  This replaces an earlier list from 1/25/12.

On Dec. 16, 2011, the Department of Health and Human Services issued an “Essential Health Benefits: HHS Informational Bulletin” outlining proposed policies that will give states considerably more flexibility and freedom in implementing the Patient Protection and Affordable Care Act.   

Essential Health Benefits Implementation Studies and Examples 

Alabama	Essential Health Benefits Benchmark Analysis - June 2012
Arizona	Essential Health Benefits, Arizona Department of Insurance - June 1, 2012
Arkansas	Selection of Arkansas' Essential Health Benefits BenchmarkPlan - September 21, 2012
	Proposed Rule 103: Essential Health Benefits Benchmark Plan - June 28, 2012
California	Interaction between California State Benefit Mandates and the Affordable Care Act’s “Essential Health Benefits - March 15, 2012
	Bills A 1453 (passd Assembly 5/14/12) / S 951 (passed Senate; passed Asembly Comm. 7/3/2012) would define the essential benefit benchmark
	Immunization Mandates, Benchmark Plan Choices, and Essential Health Benefits - June 7, 2012
	Mammography Mandates, Benchmark Plan Choices, and Essential Health Benefits - June 7, 2012
Colorado	Final Colorado Esential Health Benefits Benchmark Plan Selection - September 27, 2012
Connecticut	Essential Health Benefits Benchmark Plan - July 26, 2012
	Essential Health Benefits and Benchmark Plan Options - June 4, 2012
D.C.	Essential Health Benefits Bulletin - August 29, 2012
Delaware	Defining Essential Health Benefits for Delaware - June 15, 2012
	BCBS Small Group EPO plan
Hawaii	Hawai'i Selects Healthcare Benefits Package - October 1, 2012
Illinois	State of Illinois Comparison of Benchmark Plans
Kansas	Milliman Kansas Insurance Department Essential Health Benefits Report
	Milliman Kansas Insurance Department Essential Health Benefits Report Addendum
Kentucky	Kentucky Essential Health Benefits
Maine	Benefits provided by potential benchmark major medical plans - Feb. 1, 2012
Maryland	EHB benchmark options comparison of benefits (July 7, 2012 - DRAFT)
	EHB benchmark options comparison of state mandates (July 7, 2012 - DRAFT)
	EHB benchmark options premium impact (July 7, 2012 - DRAFT)
Massachusetts	Essential Health Benefit Benchmark Option - Commonwealth of Massachusetts
Michigan	Michigan Essential Health Benefits Comparison - May 21, 2012
	Benefits provided by potential benchmark major medical plans - data as of 3/31/12
Minnesota	Access Work Group - Feedback and Recommendation Essential Health Benefits
	Essential Benefit Set - Default Scenario
Mississippi	Mississippi Health Insurance Exchange Advisory Board Final Recommendation on Essential Health Benefits - June 13, 2012
Nebraska	High Deductible Health Plan - October 1, 2012
Nevada	Selecting the Essential Health Benefits package for Nevada’s individual and small group market - March 2012
New Hampshire	Comparison of Potential Essential Health Benefits Benchmarks
New Mexico	Primer:  Essential Health Benefits Package
New York	Essential Health Benefits Study Review of State Mandates and Potential Benchmark Plans - August 2, 2012
	Essential Health Benefits Overview - August 2, 2012
North Carolina	Analysis of Benchmark Plan Options for the Essential Health Benefits Package in North Carolina - May 2012
North Dakota	Analysis of Essential Health Benefits Under the Patient Protection and Affordable Care Act Prepared for The North Dakota Insurance Department - August 2012
Oregon	State's Essential Health Benefits Workgroup final recommendation; MEMO - July 6, 2012
Rhode Island	Essential Health Benefits - Selecting A Benchmark Plan - May, 2012
	Essential Health Benefits - Selecting and Supplementing a Benchmark Plan in Rhode Island - May 2012
	Essential Health Benefits - Comparing Benchmark Plans - June 2012
	Essential Health Benefits - Public Comments
Tennessee	Tennessee Essential Health Benefits Comparison - August 2012
	Public Comments on Essential Health Benefits - August 2012
Utah	Essential Health Benefits - Overview - June 7, 2012
	Salt Lake Tribune - Lawmakers pick Utah’s ‘bare minimum’ health plan - August 16, 2012
Vermont	Essential Health Benefits Department of Health Access (DVHA) Recommendations
Virginia	Preliminary analysis - February 2012
	Essential Health Benefit Package Subcommittee Report - June 2012
Washington	2012 enacted law, HB 2319, authorizes a state health benefit exchange and specifiies selection of the largest small group plan as the benchmark for establishing essential health benefits. Signed into law as Chapter 87, March 23, 2012

Intended Approach: Comprehensive and Flexible

"HHS intends to propose that essential health benefits are defined using a benchmark approach. Under the department’s intended approach announced Dec. 16, states would have the flexibility to select a benchmark plan that reflects the scope of services offered by a “typical employer plan.” This would give states the flexibility to select a plan that would best meet the needs of their citizens.

States would choose one of the following benchmark health insurance plans:

• 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;
• The largest HMO plan offered in the State’s commercial market by enrollment.  

If states choose not to select a benchmark, HHS has proposed that the default benchmark will be the small group plan with the largest enrollment in the state.  

The benefits and services included in the benchmark health insurance plan selected by the state would be the essential health benefits package. Plans could modify coverage within a benefit category so long as they do not reduce the value of coverage.

To prevent Federal dollars going to state benefit mandates, the health reform law requires states to defray the cost of benefits required by state law in excess of essential health benefits for individuals enrolled in any plan offered through an Exchange. However, as a transition in 2014 and 2015, some of the benchmark options will include health plans in the state’s small group market and state employee health benefit plans.  These benchmarks are generally regulated by the state and would be subject to state mandates applicable to the small group market. Thus, those mandates would be included in the state essential health benefits package if the state elected one of the three largest small group plans in that state as its benchmark. 

This approach would provide maximum flexibility to states, employers and issuers while providing quality, comprehensive, coverage for consumers."
Also read: 

• HHS Bulletin FACT SHEET on Essential Health Benefits.12/16/11  [2 pages, HTML] 
• Full essential health benefits bulletin. 12/16/11 [15 pages, PDF]
• Summary of individual market coverage as it relates to essential health benefits. 12/16/11 [2 pages]
• Report comparing benefits in small group products and state and Federal employee plans. 12/16/11  [7 pages]

IOM Issues Recommendations on Essential Benefits - Report Released Oct. 6, 2011

On Oct. 6, 2011 the Institute of Medicine (IOM) issued guidance to the Department of Health and Human Services (HHS) on "essential benefits," or mandated coverage, to be offered in the health reform law's insurance exchanges. The long awaited report, issued at the request of HHS, does not list the specific medical services to be covered (and paid for by insurers). Instead it recommends a framework of how to define the minimum benefits that will be included in insurance policies.

From the IOM Introduction: The Patient Protection and Affordable Care Act (PPACA) has made the most comprehensive changes to the provision of health insurance since the development of Medicare and Medicaid by requiring all Americans to have health insurance by 2016. An estimated 30 million individuals who would otherwise be uninsured are expected to obtain insurance through the private health insurance market or state expansion of Medicaid programs.

The success of the ACA depends on the design of the essential health benefits (EHB) package and its affordability.  - IOM Statement 10/6/2011

For the first time on a nationwide level, "costs must be taken into account," the report states. "Unless we are able to balance the cost with the breadth of benefits, we may never be able to achieve the health care coverage envisioned in the Patient Protection and Affordable Care Act. If benefits are not affordable, fewer individuals will buy insurance."

The IOM also said that HHS should define a "typical employer plan" based on the coverage provided by small employers (currently defined as up to 50 or 100 employees). The resulting package of health insurance should be based on the national average premium cost for a typical small employer plan (in 2014) and should not exceed that amount.

IOM's release summary states, "(t)he committee saw its primary task as finding the right balance between making a breadth of coverage available for individuals at a cost they could afford. This balance will help ensure that an estimated 68 million people will have access to care covered" by the Essential Health Benefits.

The report, Essential Health Benefits: Balancing Coverage and Cost is available online as an Overview, a summary Report Brief, Criteria List and free PDF (requires free account member sign up with The National Academies Press).

State Roles: As noted in the NCSL report above, all 50 states already have a total of more than 1,800 separate laws that mandate specific insurance coverage and payment. However, more than half the states also have special requirements known as mandate review or mandate evaluation laws and boards, that already can and do evaluate costs of adding new benefit coverage within their state.  The IOM also recommended that the HHS secretary grant state requests for a variant of the essential health-benefits package for those states administering their own exchanges. These will be granted where states produce a package that is “actuarially equivalent” to the national package. The IOM encouraged the HHS secretary to conduct a “public deliberative process” that it described in the report.

The IOM report urges the HHS formal list of essential benefits be announced by May 1, 2012. The report issued on October 6 does not have a binding effect.

The HHS Bulletin  "describes a comprehensive, affordable and flexible proposal and informs the public about the approach that HHS intends to pursue in rulemaking to define essential health benefits."
>  http://www.ncsl.org/documents/health/EHBbultn.pdf

Overview of PPACA mandate features

The Patient Protection and Affordable Care Act (PPACA)³ does not directly change or preempt state laws that require or "mandate" coverage of specific benefits and provider services. In the 2010-2013 start-up period, there are no direct effects on existing state health mandates. However, beginning January 1, 2014, the new PPACA Exchange marketplaces will require a more uniform, 50-state standard coverage of "essential benefits"- partly defined in statute (below) and partly subject to federal HHS regulations, being issued in preliminary form and in parts as of February 2012.  [See material and citations above.]  As noted below, starting 2014, if state laws mandate benefit features not-included in the final HHS "essential benefits" list, the state will pay any additional costs for those benefits for exchange enrollees.

Forthe first two years after the PPACA was signed (mid-2010-2012) this aspect of the law was difficult, in some cases nearly impossible, to calculate in terms of its financial, political or policy result. There are several reasons for this:

1. Existing state benefit mandates have widely different effects -- some may be used by only a small number of enrollees (such as hair prosthesis for cancer patients); others are widely accepted "good practices" that insurers already voluntarily cover in many cases (PSA tests or mammogram screening). Some have a very low incremental cost, while others can cost tens of millions of dollars across the entire insured population.
2. Insurers participating in an Exchange can in fact choose to cover selected "mandated" benefits on a voluntary basis, either at no additional charge, or with a specified policy rider which may be judged a cost-effective state investment.
3. Many state laws already have exceptions or exemptions that allow sale of certain insurance without some or all mandates. For example High Deductible Health Plans with HSAs may exclude all state mandates until the enrollee spends $1,200 or up to $5,000 out-of-pocket.
4. The "Essential Health Benefits Package"(defined in part below) already includes some of the more costly services.
5. The method by which states will calculate and “will pay any additional costs” has not yet been determined and will require new federal regulations and guidance. The cost of additional benefits may be payable to the insurer or to the individual enrollee.
6. About 33 states currently have a required state mandate review requirement, which restricts the adoption of new mandates, and is intended to analyze and in some cases justify the medical efficacy and cost-effect of these mandates.
7. States remain free to repeal, restrict, modify or expand these state mandates -- the PPACA does not interfere with this state legal process.  Federal regulations proposed in early 2012 clarify that state laws effective as of December 31, 2011 can be included in state selected EHB plans; state laws passed after that date may not be covered as EHBs within the  federal law. (Updated December 2012)

Protecting Grandfathered Plan Status⁴

For existing health insurance benefit packages and coverage plans, whose sponsors want to qualify for “grandfathered status”, the PPACA includes fairly specific requirements and restrictions on changes occurring after March 23, 2010. This includes “certain changes to benefits, including a “substantial cut to diagnose or treat a particular condition.” However, this provision is not dependent on a state law mandate – the expectation is on the insurer and the employer’s choice of benefit package – these can offer benefits within or beyond those stated in state, or in federal law. An increase in benefit coverage would have no negative effect on an employer’s grandfathered status. 

What Is a Health Insurance Exchange? Health reform requires the establishment of American Health Benefits Exchanges, or simply “exchanges,” to provide a regulated marketplace where eligible consumers can buy health insurance. Initially, individuals and small businesses will be eligible to buy health insurance through the exchanges.

Depending on their incomes, they may qualify for tax credits to help defray the cost of coverage. Individuals will select coverage through one exchange, and small businesses will select their small business coverage through another, known as the Small Business Health Options Program, or “SHOP exchange.” Beginning in 2017, states will have the option of allowing large groups to purchase coverage through the SHOP exchange. 

“Qualified Health Plans.”

Plans that meet certain qualifications can sell to individuals and small businesses in the health insurance exchange. (Those plans can sell policies at the same price outside of the exchange, as well.) To be qualified, these plans must cover the essential package of benefits, offering at least silver and gold level coverage. They can cover benefits that are outside the essential benefit package, as well, but with two caveats: 1) if they cover abortion services, they must collect separate premium checks for that coverage and cannot use any premium tax credits or other federal funding for those services; and 2) if they are required under state law to cover services beyond the essential benefit package, states will pay any additional costs for those benefits for exchange enrollees. [See law text in Appendix 2, below] 

States may also already have their own definition of qualified benefit plans that goes beyond the federal definition. While the PPACA does not legally preempt those laws, states may want to consider, at least, conforming the terms “qualified” or otherwise clarifying which provisions are federal and which are state. State and federal regulations also are very likely to play a role in implementing these provisions.

Congressional Research Analysis

The following material is excerpted verbatim from the Congressional Research Service: Report R40942, Private Health Insurance Provisions in Senate-Passed H.R. 3590, the Patient Protection and Affordable Care Act.  Footnotes #5-15 are from that report.

• “Essential health benefits package” refers to health insurance coverage that will provide “essential health benefits,” will not exceed out-of-pocket and deductible limits specified in the law, and will not impose a deductible on preventive services.
• “Essential health benefits” refers to categories of benefits specified in the law (described below) which will be provided in an “essential health benefits package.”

Essential Health Benefits Package
The Secretary will specify the “essential health benefits” included in the “essential health benefits package” that Qualified Health Plans (QHPs) will be required to cover (effective beginning in 2014). Essential health benefits, as defined in Section 1302(b) of the Patient Protection and Affordable Care Act,⁵ will include at least the following general 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 and chronic disease management
• Pediatric services, including oral and vision care.

Women's preventive health services were defined in detail via federal regulations published August 1, 2011, requiring broad coverage, without copayments or deductibles of:

• Annual preventive-care medical visits and exams
• Contraceptives (products approved by the FDA) - with exemptions for religious employers and a temporary enforcement safe harbor. [see recent developments and changes^4B]
• Mammograms
• Colonoscopies
• Blood pressure tests
• Childhood immunizations
• Domestic violence screenings for interpersonal and domestic violence should be provided for all women
• H.I.V. screenings
• Breast feeding counseling and equipment, including breast pumps at no charge.
• Gestational diabetes in pregnant women screening
• DNA tests for HPV as part of cervical cancer screening
   

2012-2013 Implementation:  New health plans are required to include these services without cost sharing for insurance policies with plan years beginning on or after August 1, 2012.  The rules governing coverage of preventive services which allow plans to use reasonable medical management to help define the nature of the covered service apply to women’s preventive services.  Plans will retain the flexibility to control costs and promote efficient delivery of care by, for example, continuing to charge cost-sharing for branded drugs if a generic version is available and is just as effective and safe for the patient to use.  (Note: 2012 health plans based on a January-December calendar year will change coverage effective January 1, 2013.)

Beginning Jan. 1, 2014, coverage provided for the essential health benefits package will provide bronze, silver, gold, or platinum level of coverage (described below).⁶ A health plan providing the essential health benefits package will be prohibited from imposing an annual cost-sharing limit that exceeds the thresholds applicable to HSA-qualified HDHPs.⁷  Small group health plans providing the essential health benefits package will be prohibited from imposing a deductible greater than $2,000 for self-only coverage, or $4,000 for any other coverage in 2014 (annually adjusted thereafter).⁸   Such limits will be applied in a manner that will not affect the actuarial value of any health plan,⁹ including a bronze level plan (described below). Consistent with the immediate reforms described above, plans providing the essential health benefits package will be prohibited from applying a deductible to preventive health services.¹⁰

PPACA will require the Secretary to define and periodically update coverage that provides essential health benefits. The Secretary will ensure that the scope of essential health benefits is equal to the scope of benefits under a typical employer-provided health plan (as certified by the Chief Actuary of the Centers for Medicare and Medicaid Services).¹¹  A health plan will be allowed to provide benefits in excess of the essential health benefits defined by the Secretary.¹²

However, if a state requires such additional benefits in QHPs, the state must reimburse individuals for the additional costs of those benefits.¹³

Essential Benefits as Applied in 2010-2013.
While the major, nationwide requirements for essential benefits will go into effect January 1, 2014, there are at least two PPACA provisions already in effect which reference use of “essential benefits”. 

• The provision which establishes restrictions on the imposition of annual limits on the dollar value of health plans effective September 23, 2010, requiring coverage value of at least $750,000 per year, refers to the “dollar value of essential health benefits (as defined in Section 1302(b) of the Patient Protection and Affordable Care Act)”, including a waiver process that allows certain plans to have a lower total value for a one-year period.

• The provision which establishes Medical Loss Ratios (MLRs), effective January 2011, references essential benefits as part of the calculation of actual medical payments by insurers.

Annual Limits and Exceptions

Under HHS regulations, plans offered between September 2010 and September 2011 may not limit annual coverage of essential benefits such as hospital, physician and pharmacy benefits to less than $750,000. The restricted annual limit will be $1.25 million for plan years starting on or after September 23, 2011, and $2 million for plan years starting between September 23, 2012 and January 1, 2014. 

HHS has approved limited, selected waiver exemptions from annual limits for selected states or employer sponsor situations.  In February, 2011 it was announced that Florida, Massachusetts, New Jersey, Ohio and Tennessee, received waivers allowing health insurance companies to continue offering less generous annual limits on benefits. In these cases, existing state law already mandates that policies with lower annual limits on coverage be offered. The Center for Consumer Information and Insurance Oversight (CCIIO), explained that because “limited benefit plans, or mini-med plans, are often the only type of insurance offered to some workers,” the one-year waivers allow continuity. 

Levels of Coverage

Beginning in 2014, PPACA will generally require QHPs to provide coverage at one of the following federally established benefit levels: bronze, silver, gold, or platinum. This requirement will apply regardless of whether or not the QHP is offered through an exchange (and premiums must be the same for QHPs inside and outside of the exchange). Excluding dental-only plans, health insurance issuers must offer a silver plan and a gold plan in the exchange. Each coverage level will be based on a specified share of the full actuarial value of the essential health benefits (see Figure 1). A health insurance issuer that offers coverage in any of these four levels will be required to offer the same level of coverage in a plan specifically designed for individuals under age 21.¹⁴

Another plan option permitted under PPACA in 2014 is a catastrophic plan. A catastrophic plan will provide coverage for essential health benefits, but coverage is paid for by the insurer only after the enrollee pays deductibles equal to the amounts specified as out-of-pocket (OOP) limits for HSA-qualified HDHPs. The exact deductible will be determined for the 2014 plan year.  As an advance example, the actual OOP limits for 2011 commercial market tax-deductible HSA/HDHP combinations are $5,950 individual / $11,900 family;  for 2012 deductible limits are $6,050 individual / $12,100 family.  Such deductibles will not apply to at least three primary care visits per plan year. A catastrophic plan will be permitted only in the individual market (1) for young adults (those under age 30 before the plan year begins), and (2) for those persons exempt from the individual mandate because no affordable coverage is available or they have a hardship exemption.   By comparison federal HSA/high deductible plan minimum deductibles for 2010-11 were established to require enrollees to pay the first $1,200 of their medical expenses ($2,400 for family coverage) before insurance benefits begin.

___________

Notes and Sources

1 .
2 Council for Affordable Health Insurance.  "Health Insurance Mandates in the States 2011."  Victoria Craig Bunce, JP Wieske.
3 The Affordable Care Act (ACA) is formally named the Patient Protection and Affordable Care Act (PPACA), Pub. L. 111–148.
4 Congressional Research Service. Grandfathered Health Plans Under the Patient Protection and Affordable Care Act (PPACA). January 3, 2011
4B - On August 1, 2011 the administration also released an amendment to the women's prevention regulation that allows religious institutions that offer insurance to their employees the choice of whether or not to cover contraception services. This regulation is modeled on the most common accommodation for churches available in the majority of the 28 states that already require insurance companies to cover contraception.  On February 20, 2012 an addition exemption was announced for employers that are charities or hospitals with a religious objection to providing contraception services as part of their health plan.  In these circumstances, the insurance company would be required to reimburse for the services.  Also the "temporary enforcement safe harbor" applies until the first plan year that begins on or after August 1, 2013.
On February 1, 2013 the "contraception rule" was further altered  to exapnde the number of groups that do not need to pay directly for this coverage. See:
- CMS Document: Fact Sheet: Women’s Preventive Services Coverage and Religious Organizations (cms.gov)
- CMS Document: Full Text of the Notice of Proposed Rulemaking on Women’s Preventive Services Coverage

CRS FOOTNOTES (#5-14) Cited in Congressional Research Service: Report R40942
5 §1302(b). [Cited in Congressional Research Service: Report R40942, Private Health Insurance Provisions in Senate-Passed H.R. 3590, the Patient Protection and Affordable Care Act.
6 §1302(d).
7 §1302(c).
8  Ibid.
9  “Actuarial value” is a summary measure of a health plan’s benefit generosity. It is expressed as the percentage of medical expenses estimated to be paid by the insurer for a standard population and set of allowed charges. For a background discussion about actuarial value, see CRS Report R40491, Setting and Valuing Health Insurance Benefits, by Chris L. Peterson.
10  §1302(c)
11  §1302(b)
12  §1302(b)(5)
13  §1311(d)(3)(B), as amended by §10104(e).
14  §1302(d).
15  Excerpted from Michael Bihari, MD, former About.com Guide editor.   Updated February 11, 2010

News and Information

A Comparative Review of Essential Health Benefits Pertinent to Children in Large Federal, State, and Small Goup Health Insurance Plans: Implications for Selecting State Benchmark Plans - American Academy of Pediatrics, July 2012

Essential Health Benefit Benchmark Plans, as of December 4, 2012 - Kaiser Family Foundation, StateHealthFacts.org, December 4, 2012

Essential Health Benefits: What Have States Decided for Their Benchmark? - Kaiser Family Foundation, December 7, 2012

Health Care Law Will Let States Tailor Benefits - New York Times, December 17, 2011

"Defining 'Typical': A Critical Step In Determining The Health Law's Essential Benefits Package" - article by State  Rep. James Dunnigan (Utah), in  Kaiser Health News, September 15, 2011

Insurance Coverage for Contraception Is Required-  The Obama administration requires health plans to cover government-approved contraceptives for women.- published August 2,2011 by NY Times.

Mandated Coverage: Several Blues Plans Face Scrutiny Over Refusal to Cover Cost of Autism Treatment - BCBS Plans Report, August 18, 2011.

---

Table 1 - State Mandated Benefit Evaluation Laws  (as of December 2012) 

These state-authorized or created programs are tasked with examining proposed new mandates or changes in existing mandates to determine the health and economic affect of such laws.  The agency links below provide examples of these state evaluations.
 

State (Total=33)	Year Enacted	Law Citation	Entity Responsible	Agency Website	Reports
Arizona	1985	Title 20, Article 3, Sections 181 - 182	Proponents Submit Report
California	2002	Health and Safety Code 127660-127665	University of California	California Health Benefits Review Program	2004 - 2011
Connecticut	2009	Public Act 09-179	University of Connecticut	Connecticut Health Benefit Review Program	2012
Florida	2002	Title XXXVII, Chapter 624, Part I, Section 624.215	Independent Research Group
Georgia	2011	Title 33, Chapter 24, Sections 60 - 67; GA SB17	Special Advisory Commission
Hawaii	2001	Chapter 23, Sections 51 -52	Mandated Health Insurance Review Panel	Department of Insurance	2001
Indiana	2003	Title 27, Article 1, Chapter 3, Section 30.2003	Interim Study Committee
Kansas	1999	Chapter 40, Article 22, Section 2248 - 2249	Insurance Department	Insurance Department	2012
Kentucky	2003	Title II, Chapter 6, Section 30, 6.948	Insurance Department	Insurance Department
Louisiana	2010	Title 24, Section 603.1	Mandated Health Benefits Commission	Office of Health Insurance	2005-2007
Maine	1998	Title 24A, Chapter 33, Section 2752	Insurance Bureau	Bureau of Insurance
Maryland	2003	Title 15, Subtitle 15, Sections 1501 - 1502	Health Care Commission	Maryland Health Care Commission	2011
Massachusetts	2002	Title 1, Chapter 3, Section 38C	Division of Health Care Finance	Division of Health Care Finance	2005
Minnesota	2003	Chapter 62J, Section 26	Commerce / Health Departments	Department of Health
Missouri	2011	Chapter 375, section 1190, subsection 3	Joint Committee on Legislative Research	Joint Committee on Legislative Research
Nevada	1989	SCR58 - 65th Session	Legislative Commission	Legislative Counsel	1991
New Hampshire	2004	Title XXXVII, Chapter 400-A, Section 39-a	Insurance Department	Insurance Department
New Jersey	2003	Title 17B, Chapter 27D, Sections 1-5	Mandated Health Benefits Advisory Commission	MHBAC	2005-2008
North Dakota	2001	Title 54, Chapter 03, Section 28	Legislative Council	ND Legislative Council
Ohio	2000	Title 1, Chapter 103, Section 14.4 - 14.6	Legislative Budget Office	Ohio Legislative Services Commission
Oregon	1985	Title 17, Chapter 171, Sections 171.870-171.880	Oregon Health Council	Oregon Health Council
Oklahoma	2009	2009 SB 822	Special Task Force
Pennsylvania	1986	Title 28, Sections 931.1-931.4	Health Care Cost Containment Council	Health Care Cost Containment Council	Reports
South Carolina	2002	Title 38, Chapter 71, Section 285	Governor's Task Force
Tennessee	2004	Title 3, Chapter 2, Section 111	Legislative Commission	Joint Committee Fiscal Review	2011
Utah			Department of Insurance	Department of Insurance	2004
Texas	2001	HB 1610	Health Plans Under Supervision of DOI	Department of Insurance	2008-2009
Virginia	1990	Title 2.2, Sections 2503-2505	Advisory Commission on Mandated Benefits	Joint Legislative Audit and Review Commission	2006-2009
Washington	1997	Title 48, Chapter 48.47, Sections 005-900	Proponents Submit Report	Department of Health	A-Z List
Wisconsin	1988	Chapter 601, Section 601.423	Department of Employee Trust Funds	Department of Employee Trust Funds

Arkansas, Colorado, New York, North Carolina - mandate review program no longer active.

Sources:
NCSL State Research; California Health Benefits Review Program.  "Other States' Health Benefit Review Programs, 2011." 

---

 Appendix I -
Background: Understanding Mandated Health Insurance Benefits¹⁵

Mandated benefits (also known as “mandated health insurance benefits” and “mandates”) are benefits that are required to cover the treatment of specific health conditions, certain types of healthcare providers, and some categories of dependents, such as children placed for adoption. A number of health care benefits are mandated by either state law, federal law — or in some cases — both. Prior to passage of the PPACA, between the states and the federal government there are upwards of 2,000 health insurance mandates.

Although mandates continue to be added as health insurance requirements, they are controversial. Patient advocates claim that mandates help to ensure adequate health insurance protection while others (especially health insurance companies) complain that mandates increase the cost of healthcare and health insurance.

Mandated Health Insurance Benefit Laws
Mandated health insurance laws passed at either the federal or state level usually fall into one of three categories:

• Health care services or treatments that must be covered, such as substance abuse treatment, contraception, in vitro fertilization, maternity services, prescription drugs, and smoking cessation.

• Healthcare providers other than physicians, such as acupuncturists, chiropractors, nurse midwives, occupational therapists, and social workers.

• Dependents and other related individuals, such as adopted children, dependent students, grandchildren, and domestic partners.

The mandated benefit laws most often apply to health insurance coverage offered by employers and private health insurance purchased directly by an individual.

Mandated Insurance Benefits and the Cost of Health Insurance
Most people – whether for or against mandates – agree that mandated health benefits increase health insurance premiums. Depending on the mandated benefit and how that benefit is defined, the increase cost of a monthly premium can increase from less than 0.1% to more than 5%.

Trying to figure out how a mandated benefit will impact an insurance premium has been very complicated. The mandate laws differ from state to state and even for the same mandate, the rules and regulations may vary.

For example: Most states mandate coverage for chiropractors, but the number of allowed visits may vary from state to state. One state may limit the number of chiropractor visits to four each year, while another state may allow up to 12 chiropractor visits each year. Since chiropractor services can be expensive, the impact on health insurance premiums may be greater in the state with the more generous benefit.

Additionally, the lack of mandates could also increase the cost of healthcare and health insurance premiums. If someone who has a medical problem goes without necessary health care because it is not covered by his or her insurance, he or she may become sicker and need more expensive services in the future.

---

Appendix 2 - TEXT EXCERPT FROM PPACA

Section 10104(e
(3) RULES RELATING TO ADDITIONAL REQUIRED BENEFITS.—
(A) IN GENERAL.—Except as provided in subparagraph (B), an Exchange may make available a qualified health plan notwithstanding any provision of law that may require benefits other than the essential health benefits specified under section 1302(b).

(B) STATES MAY REQUIRE ADDITIONAL BENEFITS.—
(i) IN GENERAL.—Subject to the requirements of clause (ii), a State may require that a qualified health plan offered in such State offer benefits in addition to the essential health benefits specified under section 1302(b).
(ii) STATE MUST ASSUME COST.—Replaced by section 10104(e)(1).
A State shall make payments—
(I) to an individual enrolled in a qualified health plan offered in such State; or (II) on behalf of an individual described in subclause (I) directly to the qualified health plan in which such individual is enrolled; to defray the cost of any additional benefits described in clause (i).