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ACA in Wisconsin, ACA: Basics

What’s Happening with Wisconsin’s Essential Health Benefits?

Essential Health Benefits (EHBs) are a fundamental part of the Affordable Care Act (ACA).  They are a way to set guidelines for what the minimum amount of coverage will be in insurance plans, while also allowing states flexibility and the freedom to influence how the ACA benefits will look in their state.  EHBs must be covered by individual and small group insurance plans inside and outside of the Exchanges (with the exception of grandfathered plans) beginning in January 2014.  In addition to the Exchanges, States have the option of regulating the entirety of the private insurance market and requiring coverage of the EHBs in all insurance plans.  This option would help alleviate the problem of generally healthier people driving up costs by purchasing catastrophic insurance outside the Exchange rather than buying insurance coverage in the Exchange.

The ten categories of EHBs in the Affordable Care Act are required benefits, and intended to provide comprehensive coverage. They establish a baseline upon which insurance plans in the Exchange can build on.

The Essential Health Benefit categories include:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

The deadline for submitting Wisconsin’s benchmark plan decision and Essential Health Benefits framework to the Department of Health and Human Services passed by on September 30 (the state administration cited a lack of guidance from the federal government.)  While missing this date does not spell the end of state contribution to ACA implementation in Wisconsin, because September 30th was a soft deadline and further guidance on EHBs will be released later this fall, it is critical that the state begin to publicly engage in this decision.

However, even without Wisconsin actively moving forward on establishing EHBs, it is still possible to determine some of what the benefits will look like in Wisconsin. What is included within each category will be determined by the type of benchmark plan that is chosen.  States had the option to choose from four kinds of plans:

  • the largest plan by enrollment in any of the three largest small group insurance products in the
  • State’s small group market; 
  • any of the largest three State employee health benefit plans by enrollment; 
  • any of the largest three national FEHBP plan options by enrollment; or 
  • the largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the State.   

According to this table from State Refor(u)m regarding states’ progress on defining EHBs and benchmark plans, less than half of states (23 and the District of Columbia) have submitted their decisions to HHS, with the majority (16) choosing the small-group plan option.  Allowing states to choose their baseline coverage in the Exchange will ensure that it mimics the “typical employer plan” and best serves the individual needs of each state’s citizens.

Wisconsin has not chosen a benchmark, and the HHS has recommended that the largest small group plan become the default framework.  United Healthcare Insurance Company’s “Choice Plus” plan would therefore become Wisconsin’s default plan.

We will continue to keep you updated as the process for determining EHBs moves forward in Wisconsin.





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