Skip to main content

10-03-2013 | Article

Most health plans fail to satisfy ACA’s essential health benefit requirements


HealthPocket study

medwireNews: Most health insurance plans are not meeting the minimum coverage standards that will kick in by 2014, according to an examination of 11,000 individual health plans across the USA.

In a study to see how far along health insurance plans are in providing the Essential Health Benefits, which will be required per the Affordable Care Act (ACA) come 2014, discovered that plans offer an average of 76% of these minimum categories of coverage while less than 2% provide all of them.

The consumer information website noted that practically all plans offer some form of benefit that covers hospitalization, emergency care, and ambulatory services. Conversely, dental and vision care for children were Essential Health Benefits that were least likely to be provided in base benefits. "Only one out of four plans nationally had these benefits within their base coverage," writes Kevin Coleman, Head of Research & Data at "[O]nly 8% of plans provided coverage for dental check-up services."

Maternity coverage was also neglected, with two-thirds of health plans not offering prenatal, delivery, and postnatal healthcare coverage to their beneficiaries.

Just over half of the plans provided inpatient and outpatient services for substance abuse issues, such as alcoholism and drug addiction, while almost two-thirds covered the evaluation and treatment of mental health issues.

Unless a health plan is exempted from having to provide the Essential Health Benefits, which requires health plans to offer coverage to individuals and small employers that meets 10 fundamental health categories, "it will have to change to survive," Coleman said to McClatchy news. "Consumers will be entitled to more health benefits in 2014 than ever before, and this will require existing health plans to expand coverage or close and be replaced by entirely new plan designs."

Massachusetts ranked as the state with the highest average coverage of Essential Health Benefits, at 94%, which is unsurprising due to the Obama administration's healthcare reform being modeled after its health reform plan.

Alaska, Louisiana, New Hampshire, Texas, and Wisconsin ranked lowest as their insurance plans on average met only 60-69% of the Essential Health Benefits categories.

"It is important to note," Coleman says, "that in 2014 some states may have broader requirements for Essential Health Benefits than others because each state has some influence on the details within each… category."

By Peter Sergo, medwireNews Reporter