Essential Health Benefits (EHBs): State Advocacy Efforts

The Department of Health & Human Services (HHS) proposes that EHBs should be defined by using a benchmark approach. Under this proposal states would have the flexibility to select a benchmark plan that reflects the scope of services offered by a "typical employer plan."

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 a state chooses not to select a benchmark, HHS intends to propose that the default benchmark will be the small group plan with the largest enrollment in the state.

The Center for Consumer Information and Insurance Oversight has issued an Illustrative List of the Largest Three Small Group Products by State (.pdf) which provides a list of the products with the three largest enrollments in the small group market in each State using data from HealthCare.gov. It provides the names of the three largest products in each State ranked by enrollment. In addition, we are providing a list of the top three nationally available Federal Employee Health Benefit Program (FEHBP) plans based on enrollment.

The benefits and services included in the benchmark health insurance plan selected by a state would be the EHB package for the state. Plans could modify coverage within a benefit category so long as they do not reduce the value of coverage. Many states have begun the process to determine which benchmark they will choose, with some states. For example, the state of Maryland is forming an "Essential Health Benefits Advisory Committee" comprised of representatives from a broad range of public stakeholders in making the selection of its essential health benefit benchmark. It is likely that as more states begin to tackle the selection of their EHB benchmark, similar committees or task forces may be set up to solicit stakeholder input.

As a number of states will likely modify coverage for rehabilitative and habilitative services, it is imperative the state chapters educate state policy makers of the benefits and cost savings of physical therapist services for the EHB, and work to ensure that unwarranted restrictions, caps, or provisions are not placed on the rehabilitative and habilitative benefit. In addition, APTA strongly encourages chapters and members to advocate and be involved in those in states that may set up stakeholder committee or solicit public input.

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