More than 20 states have decided what their benchmark health benefits should be under the 2010 reform law.
Georgia, though, has chosen to leave it to the federal government to make the decision on those benefits, the state insurance department says.
The Affordable Care Act requires insurance plans to offer a comprehensive set of benefits starting in 2014, when the law – if not repealed or gutted by Congress – is fully implemented.
States are allowed to choose a benchmark plan that would define the minimum benefits that are considered essential, as part of their work to establish online health insurance exchanges, set to open in 2014.
It’s one of the major decisions that states must make in respect to the Affordable Care Act. More important to health care systems, though, are two other reform-related choices by states – whether to expand Medicaid, and whether or how to create their own insurance exchanges.
If a state decides not to choose its essential health benefits, the default benchmark plan will be the largest small-group plan in that state.
The federal Department of Health and Human Services had already identified that plan in Georgia — a small-group policy offered by Blue Cross and Blue Shield of Georgia.
Essential benefit requirements apply to individual and small-group plans sold inside and outside the state-based exchanges in 2014. The requirements also apply to benefits provided to those newly eligible for Medicaid coverage.
These requirements do not apply to self-insured health plans, which most large employers use to cover their workers.
In July, a state insurance official noted that the small-group Blue Cross plan does not cover pediatric vision and dental services, two of the essentials under the law.
A statement Monday from Glenn Allen, spokesman for Georgia Insurance Commissioner Ralph Hudgens, criticized the federal rules on defining the benefits plan as an unsatisfactory basis for the state to make a decision.
“We did not have enough discretion to ensure that Georgians had access to comprehensive but cost-effective plans,’’ the statement said. “Additionally, the federal rules did not give Georgia clarity on how some of the [Affordable Care Act’s] mandated benefits should be supplemented into plans already offered in Georgia.
“Given the incomplete and overly restrictive nature of the federal rules, we believe the federal government should implement the process it created,’’ the statement concluded.
All insurance plans sold to individuals and small businesses will have to cover items and services in a minimum of 10 categories defined by the 2010 law, including preventive care, emergency services, pediatric care (including oral and vision care), maternity care, hospital and physician services, and prescription drugs.
Self-insured employers are exempt from the essential benefit requirement, but most large employer plans already cover those 10 broad categories.
The benefits decisions are perhaps most important to people with chronic health conditions.
“We know that historically, some cancer patients have not received all of the services necessary to fully treat their condition,’’ Stephen Finan, senior director of policy for the American Cancer Society Cancer Action Network, said recently.
“The essential health benefits requirement is a vital step toward ensuring that coverage will be based on what is medically necessary and appropriate to treat a condition, rather than arbitrary limits that sometimes exist in health plans offered today,’’ he said.
Cindy Zeldin, executive director of Georgians for a Healthy Future, said Monday that her group always prefers to see state policymakers “involved as much as possible in these types of decisions.’’
“This process is important because it sets the floor for meaningful coverage,” she said. “Georgia consumers purchasing health insurance deserve the peace of mind that comes from knowing that they are purchasing a quality plan that meets basic standards and that will provide adequate protection in the event they get sick.”
But Zeldin also noted that the fallback benefits package will now kick in, and that consumer advocates and stakeholders will have an opportunity to comment on it.
Much more momentous to Georgia, she said, is the state decision whether to expand its Medicaid program under the reform law.
Gov. Nathan Deal has said he opposes Georgia expanding Medicaid under the current federal rules. He has also expressed support for a block grant for Medicaid, a position supported by Republican presidential candidate Mitt Romney.
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