The Other Mandate Issue in the ACA: Benefit Mandates

One issue that states will need to confront in the future is how to reconcile state benefit mandates with new federal benefit requirements. Some states have already begun to consider the role of benefit mandates post health reform:

• Maryland’s Health Reform Coordinating Council has identified some key steps they will need to take once federal guidance on essential health benefits (EHBs) is released.
• California, which has its own Health Benefits Review Program, wrote an issue brief analyzing their state mandates in relation to the broad benefit categories laid out in ACA.

Much of states’ work will depend on the federal government’s definition of EHBs for qualified plans sold through the Exchanges. The Affordable Care Act (ACA) lays out ten broad categories of required benefits, which will be refined through federal regulation. Federal law requires EHBs be at least equal to the scope of benefits under a typical employer plan. A Center for Consumer Information and Insurance Oversight (CCIIO) official reported that guidance from the federal government on EHBs is expected to be released in late 2011.

In order to inform federal rulemaking, the Department of Labor is conducting a survey of employer-sponsored coverage. Also, at the request of the Secretary of HHS, the Institute of Medicine (IOM) is undertaking a study that will make recommendations on the criteria and methods for determining and updating EHBs, but it will not define the benefits themselves. TheIOM study panel held a meeting on January 12, 2011, and will meet again publicly in March 2011. In addition to researchers, insurers and others, presentations were made by representatives fromMassachusetts, Utah, and Maryland (B. Sammis, R. Cowdry). These presenters shared state experience in determining covered benefits, making medical necessity determinations, and understanding the health care needs of varying populations.

Once the federal government takes action, states will need to analyze the regulations in relation to their benefit mandates and decide whether they want to continue or eliminate them. Continuing these mandates may mean additional costs to states in order to provide these benefits to people participating the Exchange, as set forth in ACA (Section 1311(d)(3)(B)). The California Health Benefits Review Program brief examines this issue.

Has your state begun to look at how to reconcile state benefit mandates with new federal benefit requirements under the ACA? Share resources on these issues or others by sending them to State Refor(u)m.