While open enrollment for 2016 has just started, the planning for 2017 has already begun. Earlier this week, CMS published information for all the state plan benchmarks for the essential health benefits (EHBs) that are required in each qualified health plan (QHP) which will be offered in the 2017 marketplace. Under the Affordable Care Act (ACA), every QHP is required to cover 10 EHBs and each state is tasked with selecting a plan offered in the state to act as the benchmark for the EHBs subject to certain HHS guidelines. The 10 EHBs required under the ACA include:
- Outpatient care
- Trips to the emergency room
- Treatment in the hospital for inpatient care
- Care before and after a baby is born
- Mental health and substance use disorder services, including behavioral health treatment, counseling and psychotherapy
- Prescription drugs
- Services and devices to help you recover if you are injured, or have a disability or chronic condition, including physical and occupational therapy, speech-language pathology, psychiatric rehabilitation and more.
- Lab tests
- Preventive services including counseling, screenings and vaccines to keep you healthy and care for managing a chronic disease.
- Pediatric services, including dental care and vision care for kids
It should be noted that CMS acknowledges that some of the state benchmark plans may not comply with the ACA EHBs requirements as the plans from which they were selected existed prior to the ACA implementation. What does this mean for navigators? It means that just because a certain area is listed as a covered area in the EHBs, a consumer should not assume it will be covered in the plan that they select. Navigators should ensure that consumers fully evaluate what a plan covers before they select it so that they know it will meet their needs.
For more information on the CMS announcement for the EHBs, check out the Health Affairs blog post this week by clicking here.