By: Olivia Szwalbnest, NACHC Intern and Susan Sumrell

You may remember that just before the holidays, we told you that HHS released a Bulletin that described the intended approach for defining the essential health benefits (EHB) under the Affordable Care Act. In follow up to that Bulletin the Centers for Medicare & Medicaid Services (CMS) created a Frequently Asked Questions on Essential Health Benefits Bulletin, which clarifies some questions on the Bulletin. These FAQs address the EHB benchmark plan that each State must select by the third quarter of 2012. Each State’s benchmark plan will take effect for the plan years 2014 and 2015. HHS intends to revisit the essential health benefits approach described in the Bulletin for the plan years beginning in 2016.

Of particular interest to health centers, several of these answers are directly related to the effect EHB will have on current Medicaid recipients and those who will become eligible for Medicaid under the Affordable Care Act as of January 1, 2014. First, CMS explains that all Medicaid benchmark and benchmark equivalent plans must include at least all ten of the EHB statutory categories by January 1, 2014. These benchmark plans are based on of three commercial insurance products or a “Secretary-approved” coverage option. Unlike the EHB benchmark plan described in the Bulletin, there will be no default EHB reference plan for Medicaid. Instead, each State Medicaid Agency will be required to select an EHB benchmark reference plan for Medicaid purposes as part of its Medicaid State Plan changes in 2014. Additionally, a State is not required to choose the same EHB benchmark reference plan for Medicaid section 1937 plans as it does for the individual and small group market. Moreover, the State can have more than one EHB benchmark reference plan for Medicaid. However, if a State so chooses, it may propose its traditional Medicaid benefit package, under the “Secretary-approved” option available under section 1937. As previously stated, the State must ensure that it includes all ten statutory categories of EHB into these plans.

For more information on the Bulletin, the Essential Health Benefits Bulletin may be accessed here.