Health Care Costs
CMS reopens the rules for ACA essential benefits
The agency is asking whether benchmark plans and the typical-employer-plan test still fit today’s market, where costs, coverage patterns and employer benefits have shifted.
CMS is seeking public comment on the Essential Health Benefits framework, including how states choose benchmark plans and how the typical-employer-plan standard should work. The review could shape what ACA plans must cover, and how much patients pay out of pocket.
- CMS is reviewing the ACA coverage floor, not changing it yet.
- State benchmark plans help define what counts as essential coverage.
- The review could affect benefits, premiums and out-of-pocket costs.
- The agency is also reexamining the link to typical employer plans.
- People buying Affordable Care Act coverage could eventually feel this in the most practical way possible: what their plan pays for
People buying Affordable Care Act coverage could eventually feel this in the most practical way possible: what their plan pays for. At the federal level, the Centers for Medicare & Medicaid Services, part of the Department of Health and Human Services, is reviewing the Essential Health Benefits, or EHB, framework, the floor that helps determine the minimum package of benefits in ACA plans. The agency says it wants to know whether the current rules still fit today’s insurance market and health care costs.
The review also reaches the ACA requirement that EHB be equal in scope to the benefits offered under a typical employer plan. That comparison matters because it helps define what counts as essential coverage for many individual and small-group plans, not just plans sold through the health law’s marketplaces.
The floor that decides what gets covered
Under current rules, states use benchmark plans as reference points for the benefits considered essential in each state. CMS is asking whether its current interpretations of essential health benefits still make sense, how it should decide what counts as EHB, whether the agency should rely more on data such as commercial claims or employer coverage surveys, and whether self-funded plans are represented well enough in the system.
The agency is also asking about the scope of benefits itself, including how much variation should be allowed across states and whether benefit updates should be judged through actuarial value, or AV, a measure insurers use to compare how much a plan pays versus how much enrollees pay.
Why shoppers would notice
CMS says changes to the current framework could affect affordability, market stability, state flexibility and access to services. That is a dry way of saying the rules can influence what plans must include, how much room insurers have to design products and whether patients run into gaps when they need care.
State EHB-benchmark plans set the baseline for essential health benefits, and those benchmarks shape coverage in ways that can differ from a typical employer plan. CMS says the information it gathers will help it decide whether revisions or additions to the EHB regulations may be appropriate.