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Study: Employer Mandate Delay Will Have Little Impact on Coverage, Revenue

A one-year delay of the employer mandate provision of the Affordable Care Act will have little effect on coverage and revenue, according to a new study from RAND Corporation. Only 300,000 fewer people, or 0.2 percent of the population, will have access to employer-sponsored insurance in 2014 because of the delay, the study found. And only about 1,000 fewer businesses will offer coverage.

That’s in part because less than 5 percent of businesses have 50 or more employees, which is the point at which the employer mandate kicks in (smaller businesses are exempt). Of these larger businesses, 95 percent already offer health insurance to employees, according to the study.

The study also found that the financial impact of the delay does not figure to be overly significant. Estimates show that the federal government will miss out on about $11 billion in revenue, which is far less than the total revenue the law is expected to generate. However, if the employer mandate was repealed completely, revenue would fall by $149 billion over the next 10 years because of lost penalties—about 10 percent of the total spending offsets being used to support the law.

“Our simulations show the one-year delay of the large-employer mandate will not have a substantial impact on either enrollment in health insurance or financial support for the Affordable Care Act,” said Carter Price, the study’s lead author and a mathematician at RAND, a nonprofit research organization. “However, eliminating the large-employer mandate would have a significant impact on financial support for many provisions of the Affordable Care Act.”

The Obama administration announced the delay in early July. Originally, the law required that employers with 50 or more full-time workers provide health insurance by the start of 2014, or pay penalties. Now, these businesses have until 2015 to comply.

The full study is available at http://bit.ly/16shiv7.

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HOSPITAL MERGERS COULD SQUEEZE COLLECTION AGENCIES

Hospitals across the nation are merging at a rapid pace these days—a trend that will impact the health care collections industry in numerous ways. Mergers are occurring at the fastest rate since the 1990s, the New York Times reported in a recent article (http://nyti.ms/16S1nqe). Various factors are driving the trend, including implementation of many parts of the Affordable Care Act over the next two years.

In particular, hospitals find themselves being paid less on volume under the health care law and more on the quality of care they provide, the Times noted. That means there is less of an incentive to keep beds full, and more incentive to keep patients healthy and out of the hospital. This encourages providers to merge, reduce overhead costs, and focus instead on implementing expensive electronic medical records systems that allow them to more effectively track and evaluate patients.

Consulting firm Booz & Company predicts that 1,000 of the nation’s roughly 5,000 hospitals could seek out mergers in the next five to seven years, according to the Times. ACA International member Chris Becraft—who is president of Collection Service Bureau, Inc. in Phoenix, which specializes in health care receivables management—said the industry is going through its “biggest roll-up ever.”

“Large systems are needing to either grow organically, through opening up new facilities or services, or purchase others,” he said. “Independent facilities are unable to make a profit with the current state of government reimbursement so they either need to merge or go out of business. The independent regional hospitals are an endangered species and I predict there will be very few left in five to seven years.”

Becraft added that he sees some problems for collection agencies as a result of these mergers. “What this means is there are fewer clients for collection agencies to do business with today and there will be far fewer in the future,” he said. “There is very little hope for the smaller agency to remain viable exclusively in health care unless they are content with the ever-shrinking margin and market they will be getting from small providers.”

Becraft said the mergers topic is frequently discussed among staff at his agency. “It’s a very big topic with staff,” he said. “When a change happens, that is when we can either gain business or lose it. More agencies will be losing business because of this than gaining, I can guarantee you that. We intend to be on the gaining side and are growing aggressively to be able to continue servicing these larger providers.”

Becraft added that it’s not just hospitals that are merging—many collection agencies are merging as well, in an effort to stay viable in the health care collections field.

“Larger health care providers will eventually only want to do business with other large entities because that is what will make sense to them,” he said. “The future of high volume health care RCM will be the exclusive domain of large companies because that is all that will exist eventually in both industries.”

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Electronic Health Records Can Reduce Costs

Use of electronic health records can reduce the costs of outpatient care by roughly 3 percent, compared to relying on traditional paper records, according to a new study. The University of Michigan compared health care costs of 179,000 patients in three Massachusetts communities that widely adopted electronic health records with six control communities that did not.

The resulting study, “Effect of Electronic Health Records on Health Care Costs: Longitudinal Comparative Evidence from Community Practices,” was published on July 16 in the Annals of Internal Medicine. On average, the researchers estimated $5.14 in savings per patient per month in the communities with electronic health records versus those without electronic records.

“I think our findings are significant because we provide evidence to support the use of taxpayer dollars to invest in electronic health records,” said Julia Adler-Milstein, an assistant professor at the university who led the study.

“We really have not had compelling evidence that proved that they would save money. It was assumed, but there are a lot of skeptics. This study helps clarify whether there are cost savings and what the magnitudes of those are in the near-term.” The full study is available at http://bit.ly/18hILhf.

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ACA International, HFMA Team up for New Task Force

ACA International has partnered with the Healthcare Financial Management Association (HFMA) to identify best practice recommendations for medical debt collection. The HFMA Medical Debt Task Force formed in February, a result of earlier discussions involving various stakeholders in the medical debt collection industry. Lucia Lebens,

ACA International’s director of federal government affairs said the idea was to develop clear guidelines that could be used across the healthcare industry.

“It was clear… that there was a lot of education to be done, as to how the process worked from when a patient left a Hospital or clinic all the way to the end of the billing cycle,” Lebens said. With HFMA and ACA International spearheading the effort, representatives from across the industry got on board, including health system CFOs, medical debt collection experts, credit reporting representatives and consumer advocates.

Lebens said members wanted to be proactive and establish recommended best practices, limiting the chance of government regulators laying out their own set of rules without any kind of input. “If we don’t do this, it’ll be done for us,” Lebens said. When the task force first met, members broke up into smaller workgroups to develop initial ideas. “That was a good starting point,” Lebens said. “Then we came together and meshed the ideas.” Using the tenets of HFMA’s Patient Friendly Billing project—that health care financial communications should be clear, concise, correct and patient-friendly—the task force developed a draft flowchart that could be adopted industry wide.

The flowchart lays out a step-by-step guide to how, ideally, medical debt collections should be handled, from the initial billing through potential legal actions for delinquent debts. Along the lines of being patient friendly, the task force recommends that providers be clear with patients about what they owe early and often. Other recommendations include identifying eligibility for public programs and/or financial assistance earlier in the process, and allowing patients to have 120 days to pay a bill before reporting delinquent debt.

The task force hopes that developing a uniform process will simplify things for patients, which should ultimately lead to better account resolution statistics. As it stands, health care providers often use different processes to resolve accounts, which contribute to patient confusion and increase the likelihood that medical debts go unpaid. Lebens said a lot of agencies in the industry already use a lot of the best practices that have been laid out, but added it was important to identify and define them in one place.

What the task force has produced so far is just a draft, however. Following a presentation at ACA’s recent annual convention, task force members brought the draft back to their respective organizations. Comments and suggestions will be gathered from these stakeholders, and the draft will be edited as needed. Lebens said she hopes a final document gets ACA and HFMA approval in the fall. From there, Lebens said she hopes that the final product can be used as an educational resource in Washington, D.C. According to Lebens, a Congressional briefing could be scheduled before the end of the year, which would provide great positive exposure for the medical debt collection industry.

“There’s been a lot of interest about this on Capitol Hill,” Lebens said. “It’s a very relevant topic.” Lebens added that by forming a proactive task force, industry stakeholders are trying to ensure that they have a seat at the table when lawmakers do address medical costs and debt. “Let’s help get the message out there that we’re working together and build some good will,” she said. If you are interested in learning more about this task force, please contact Lucia Lebens at lebens@acainternational.org.

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CMS Releases Additional Data on Health Care Spending

In June, the Centers for Medicare & Medicaid Services released selected data on hospital outpatient charges as well as county-level data on Medicare spending and use for the first time. Among the data sets issued by CMS are one on Medicare spending and use (http://go.cms.gov/17RGVGP), and another on Medicare beneficiaries with chronic conditions (http://go.cms.gov/11dkxhP).

Both data sets will enable researchers, data innovators and the public to better understand Medicare spending and service use, spurring innovation and increasing transparency, while protecting the privacy of beneficiaries. The data is also available through an interactive state-level dashboard (http://go.cms.gov/16JU5lu) based on the spending information, allowing users of any skill level to quickly access and use the data.

Building on the previous CMS release of the average charges for the 100 most common inpatient procedures, CMS also released selected hospital outpatient data (http://go.cms.gov/130y8eT) that includes estimates for average charges for 30 types of hospital outpatient procedures from hospitals across the country, such as clinic visits, echocardiograms and endoscopies.

In May, CMS released data reflecting significant variation across the country and within communities in what hospitals charge for common inpatient services. For example, average inpatient charges for services a hospital may provide in connection with a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif.

Even within the same geographic area, hospital charges for similar services vary significantly. For example, average inpatient hospital charges for services that may be provided to treat heart failure range from a low of $21,000 to a high of $46,000 in Denver, Colo., and from a low of $9,000 to a high of $51,000 in Jackson, Miss.

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Historic Slowdown in Health Care Spending Growth Projected for 2014

Health care inflation in the U.S. is projected to dip to 6.5 percent in 2014, according to PricewaterhouseCoopers’ Health Research Institute (HRI) in its annual report, “Medical Cost Trend: Behind the Numbers.” The ongoing slowdown in the health care growth rate defies historical post-recession patterns and is likely to be sustained even as the Affordable Care Act adds millions more newly insured Americans to the health system next year.

The decline in spending growth is a signal of progress in the quest to bend the cost curve. At the same time, the slowdown presents financial challenges for the industry as it attempts to navigate in a rapidly changing environment. According to HRI, structural changes within the industry are helping to contain costs and deliver care more efficiently. Consumers, meanwhile, who are paying a greater share of the cost, are making spending adjustments. Many are delaying care, using fewer services and choosing less expensive options such as retail clinics, urgent care centers and mobile health devices “The health industry is at an inflection point as it rebalances, realigns and prepares for full-scale transformation from fee-for-service medicine to consumer-centered, accountable care,” said Kelly Barnes, PwC’s U.S. health industries leader. “Change of this magnitude takes time and will come in stages. Health organizations should learn to adapt to a market in which growth may be lower in the near term, and pursue new sources of growth often in unlikely places.”

Medical cost trend—or growth rate—reflects changes in the actual cost to treat patients and is influenced primarily by the cost of products and services and the number of services used, or per capita use. The trend is a key ingredient in setting insurance premiums. After accounting for likely changes in benefit design, such as higher deductibles, HRI projects a net growth rate of 4.5 percent in 2014.

According to HRI, health organizations that already have been hurt by a squeeze on reimbursement and a recession hangover should brace for additional financial pressure. Uncertainty about the impact of Affordable Care Act implementation and what to expect from a largely unknown, newly insured population are manifested in seemingly contradicting themes: a declining medical cost trend and rising insurance premiums, particularly in the individual market.

“Health care cost increases continue to exceed overall growth in wages, but the gap appears to be shrinking. The long term trends suggest that as the economy improves, the cycle of runaway cost increases will be broken,” said Michael Thompson, principal with PwC’s human resource services practice. “This is critical as employers strategically reevaluate the role of health care benefits to their organizations and step up efforts to engage employees more directly in value-based health care decision making.”

Major employers are beginning to contract directly with big name health systems to tackle expensive and complex procedures for employees, such as heart surgery and spinal fusion. According to PwC’s “Touchstone Survey,” 33 percent of businesses are considering high-performance networks over the next year. Early data suggests this could mean as much as a 25 percent reduction in costs. To explore the findings and watch video commentary, visit:

www.pwc.com/us/MedicalCostTrend.

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The Massachusetts Experience

As the nation prepares for implementation of major provisions of the Affordable Care Act, an analysis of the health reform experience in Massachusetts from PricewaterhouseCoopers’ Health Research Institute (HRI) sheds light on the potential implications for the rest of the nation’s health sector.

Major regulatory changes continue to drive industry consolidation. Nearly one third of the 70 acute care hospitals in Massachusetts have been involved either in a merger, acquisition or partnership since 2007, and another 20 percent are in various stages of discussion. By contrast, only about 9 percent of Massachusetts hospitals are entirely independent, raising doubts about the long-term viability of stand-alone community hospitals in the United States.

“The rapid pace of activity in Massachusetts reflects broader consolidation trends across the country,” said Robert Valletta, PwC U.S. health care provider leader. “Innovative partnerships can lead to new payment models that reward coordinated, team-based care as opposed to volume of procedures. Our analysis suggests the lessons learned in Massachusetts can offer insights to health industry executives across the nation as they prepare to adapt to the new landscape.”

Health plans may encounter financial instability after major regulatory changes are enacted, the data suggests. While the new enrollment in Massachusetts led to higher combined revenues across the state’s largest health plans, profits varied widely in the years following enactment of the law, HRI found.

Providers in Massachusetts have experienced more subtle financial effects: profit margins leveled out. Between 2005 and 2010, academic medical centers saw a 1.4 percent margin increase, while other hospital types saw increases below 1 percent over the same period. Hospitals in the state have experienced a decline in the use of emergency departments, as consumers access primary care in lower-cost settings. Today, the state is seeing signs of improved health among residents and positive changes in patient behavior, but also persistently high costs, which the state is continuing to address.

The Massachusetts experience should provide a good preview of what the country as a whole should expect come Jan. 1, when one of the last pieces of the Affordable Care Act—the requirement that all Americans carry health insurance, or pay a fine—goes into effect.

CNN Money reports that the Massachusetts law has a similar insurance mandate, plus tough rules for when employers must offer plans and the blueprint for a government-run online insurance marketplace, or exchange.

Ultimately, the Massachusetts law served as a model for the Affordable Care Act.

“I give a lot of talks to groups from outside the state,” Andrew Dreyfus, CEO of Blue Cross Blue Shield of Massachusetts, told CNN Money, “and I often begin, ‘Hi, my name is Andrew Dreyfus, and I am from the future.’”

So what has happened in Massachusetts since its reform went into effect in 2007? In addition to the industry consolidation, the state has also experienced a drop in uninsured residents. The uninsured rate is down from 8 percent in 2007 to 3 percent today, according to CNN Money. (Nationally, the uninsured rate is expected to drop to 10 percent—it’s at 16 percent today—by 2017.)

Costs might be a bit harder to predict on a national level. On average, Massachusetts individual plan shoppers saw their premiums drop by 33 percent the year after the reform went into effect. But this might not be a good indicator of what to expect nationally: Massachusetts already guaranteed coverage before its reform; meaning healthy consumers and the seriously ill had previously been grouped together when setting premiums. Nationally, an influx of sick people qualifying for insurance could raise premiums by 20 to 45 percent, CNN Money reports.

“Insurers will err on the side of overpricing and then rebate funds if they have to,” Robert Hurley, senior vice president at eHealthInsurance.com, told CNN Money. The report adds that consumers will have a better idea of costs sometime this summer, when states begin announcing details of their health insurance exchanges.

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84 Million People Were Uninsured or Underinsured in 2012

Eighty-four million people—nearly half of all working-age U.S. adults—went without health insurance for a time last year or had out-of-pocket costs that were so high relative to their income they were considered underinsured, according to the Commonwealth Fund 2012 Biennial Health Insurance Survey.

The survey also found that the proportion of young adults ages 19-25 who were uninsured during the year fell from 48 percent to 41 between 2010 and 2012, reversing a nearly decade-long trend of rising uninsured rates in that age group. This reversal is likely due to this Congress by Sen. Jeff Merkley (D-Ore.) in the Senate, and versions were introduced in both the House and Senate last Congress.

This new legislation is substantially similar to The Medical Debt Relief Act of 2010 (H.R. 3421), which was introduced by former Rep. Mary Jo Kilroy during the 111th Congress. H.R. 3421 passed the House of Representatives under suspension by a recorded vote of 336 to a provision in the 2010 Affordable Care

Act allowing young adults to stay on their parents’ health insurance until age 26, the authors said.

The report, “Insuring the Future: Current Trends in Health Coverage and the Effects of Implementing the Affordable Care Act,” found the percentage of Americans who were uninsured, underinsured or had gaps in their health coverage grew steadily between 2003 and 2010, with the number of underinsured nearly doubling from 16 million in 2003 to 29 million in 2010

However, between 2010 and 2012, the numbers of underinsured adults leveled off, growing to 30 million. The authors say that this is partly a result of slower health care cost growth and lower overall health spending by consumers, combined with declining household incomes. But provisions in the health reform law—such as requiring insurers to cover recommended preventive care without any cost to patients—also are beginning to make health care more affordable for many consumers.

According to the survey, people are increasingly skipping needed health care because they can’t afford it. In 2012, 80 million people reported that, during the past year, they did not go to the doctor when they were sick or did not fill a prescription due to cost. Reports of skipping needed care rose substantially from 2003, when 63 million people did not get care because of cost.

Medical debt also continues to burden U.S. households. According to the report, in 2012, 41 percent of working-age adults, or 75 million people, had problems paying their medical bills or were paying off medical bills over time, up from 58 million in 2005. Nearly one of five (18 percent) adults were contacted by a collections agency over unpaid bills, and 16 percent had to change their way of life because of medical bills. The report finds that medical debt has substantial consequences: 42 percent of survey respondents who reported having trouble with medical bills, or an estimated 32 million people, had a lower credit rating because of unpaid bills and 6 percent, or an estimated 4 million, had to declare bankruptcy because of their bills. View the full report at http://tinyurl.com/b9qq3pr.

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Obamacare Health Plans Vastly Different State to State

Little time is left until the new health insurance exchanges that came about as a result of the Affordable Care Act are open and selling health insurance to millions of people throughout the country. While this may be good news for those who did not previously have access to affordable health insurance, it is becoming clear that those who are planning to purchase their coverage through these exchanges will have very different choices depending on the area in the country that they live.

Some states such as Colorado, Maryland, and California have been able to attract many different insurers. California, for example, will have 13 insurers who are likely to offer a wide array of plans. Of the 13 insurers, there are notable names including some of most popular, best-known, and largest insurance carriers. But the story is drastically different for people in other states where options might be limited to a predominately local carrier or a completely unknown option, with no proven record in providing health coverage for individuals.

The Obama administration has suggested that the majority of Americans will have a choice of at least five carriers when open enrollment begins this October. There have also been encouraging signs that both existing and new insurers are working to provide plans that are competitive from the standpoint of affordability as well as creativity. These exchanges will be open to millions who are currently uninsured or who are already purchasing individual coverage for themselves and Federal subsidies will be available to many.

But people in some parts of the country may not have the same hearty level of insurance choices which means fewer insurers with instantly recognizable names to choose from. Inevitably, this will force some to take a chance on plans that are offered by insurers who are new to the individual health market and carriers who are brand new to the health insurance marketplace altogether. Not only will choices in providers be varying, but costs of insurance are expected to vary greatly as well.

It is probable that other companies will delay entry into the health insurance exchange until they see opportunity and the prospect of gaining new customers. The fact that there is a relative uncertainty over how well the exchanges will work and be received makes it likely that many companies will only enter the market after it is clear that a noteworthy number of customers exist.

The law was designed to encourage competition in the marketplace and, in fact, 25% of the companies offering plans on the 19 Federal exchanges are brand new to the marketplace according to a recent memo released. Using the State of Massachusetts as a case study for obvious reasons, it becomes apparent that a health plan that is new and unknown might not prevent it from becoming well-received quickly. In Massachusetts, an insurer that was basically unknown went on to capture a large share of the market. However, to remain competitive, insurers are going to have to search for opportunities to offer plans inexpensively.

Consumer-operated plans, or co-ops, will likely pressure other insurers to keep prices low since they might gain a larger market share by offering lower premiums. A consumer-operated insurer would typically charge little more than the actual costs of medical care and can even lower premiums when possible. Plans that specialize in Medicaid or government programs for low-income people might become an imposing competitor because they focus on serving their population segment.

Many within the insurance industry continue to speculate about how all of this will ultimately unfold. However, many knowledgeable industry insiders are conceding that it will likely take years for the new health exchange system to fully develop.

mistydawnphoto / Shutterstock.com

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Health Care Coverage Still Uneven Across U.S.

On April 16, 2013, Gallup released a report showing that one in five Americans remain uninsured in 43 metro areas. Large discrepancies in health insurance coverage across the U.S. metro areas continued in 2012. However, according to Gallup, this may change as the centerpieces of the 2010 Affordable Care Act begin to go into effect – health insurance exchanges and the individual mandate.

The 10 metro areas with the highest percentage of uninsured residents are:

1. McAllen-Edinburg-Mission, Texas: 48.8 percent

2. El Paso, Texas: 31.7 percent

3. Yakima, Wash.: 31.0 percent

4. Naples-Marco Island, Fla.: 30.0 percent

5. Visalia-Porterville, Calif.: 29.8 percent

6. Bakersfield, Calif.: 28.7 percent

7. Salinas, Calif.: 27.9 percent

8. Stockton, Calif.: 27.8 percent

9. Las Vegas-Paradise, Nev.: 26.1 percent

10. Houston-Sugar Land-Baytown, Texas: 26.1 percent

The 10 metro areas with the lowest percentage of uninsured residents are:

1. Burlington-South Burlington, Vt.: 4.1 percent

2. Boston-Cambridge-Quincy, Mass.-N.H.: 4.3 percent

3. Springfield, Mass.: 4.8 percent

4. Worcester, Mass.: 5.6 percent

5. Ann Arbor, Mich.: 6.3 percent

6. Rochester, N.Y.: 6.4 percent

7. Madison, Wis.: 6.7 percent

8. Barnstable Town, Mass.: 7.1 percent

9. Harrisburg-Carlisle, Pa.: 7.5 percent

10. Buffalo-Niagara Falls, N.Y.: 7.9 percent

The 2012 metro area data were collected as part of the Gallup-Healthways Well-Being Index. The nationwide adult uninsured rate of 16.9 percent in 2012 was similar to the 17.1 percent in 2011, but remains up from 2008 (14.8 percent) and 2009 (16.2 percent). The metro areas with the highest and lowest uninsured rates have changed little over time.

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Rule Finalized Guaranteeing 100 Percent Funding for New Medicaid Beneficiaries

The U.S. Department of Health and Human Services (HHS) announced a final rule with a request for comments that provides, effective Jan. 1, 2014, the federal government will pay 100 percent of the cost of certain newly eligible adult Medicaid beneficiaries. These payments will be in effect through 2016, phasing down to a permanent 90 percent matching rate by 2020. The Affordable Care Act authorizes states to expand Medicaid to adult Americans under age 65 with income of up to 133 percent of the federal poverty level (approximately $15,000 for a single adult in 2012) and provides unprecedented federal funding for these states.

The final rule provides important information to states that expand Medicaid. It describes the simple and accurate method states will use to claim the matching rate that is available for Medicaid expenditures of individuals with incomes up to 133 percent of poverty and who are defined as “newly eligible” and are enrolled in the new eligibility group. The system is set up to make eligibility determinations as simple and accurate as possible for state programs.

Under the Affordable Care Act, states that cover the new adult group in Medicaid will have 100 percent of the costs of newly eligible Americans paid for by the federal government in 2014, 2015 and 2016. The federal government’s contribution is then phased-down gradually to 90 percent by 2020, and remains there permanently. For states that had coverage expansions in effect prior to enactment of the Affordable Care Act, the rule also provides information about the availability of an increased Federal Medical Assistance Percentages for certain adults who are not newly eligible.

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24 States Have Selected Their Benchmark Health Insurance Plan for Essential Health Benefits

Twenty-four states and the District of Columbia have selected the health insurance plan in their state that will serve as the “essential health benefit” package sold by all insurers participating in the new health insurance marketplace and the individual and small-group markets beginning January 2014, according to a Commonwealth Fund study announced on March 13, 2013. The essential health benefit covers 10 broad service categories, including ambulatory patient care, hospitalization, maternity and newborn care, and prescription drugs. The federal government allowed each state to choose a benchmark plan to help meet the Affordable Care Act requirement that the essential health benefit reflect a typical employer health insurance plan.

The authors of the study found that 19 of the states that selected plans chose existing small-group plans—typically employer-based plans for businesses with fewer than 50 employees. The remaining five states selected HMO or state employee benefit plans. For states that did not select a benchmark plan, the federal government will designate the largest small-group plan in the state as the benchmark, meaning that the majority of states will have the most widely purchased small-group plan in the state as the basis of their essential health benefit.

In an in-depth investigation into how 10 states arrived at their benchmark plan, the authors found that states conducted analyses of plan enrollment and costs, and engaged consumer and patient groups, insurers, and specialty physicians in their decision-making process. The desire to preserve state benefit mandates not included in the federal essential health benefit package was also a factor in choosing benchmark plans.

The Department of Health and Human Services (HHS) will evaluate the benchmark selection process and may choose to revisit it in 2016. If that is the case, the authors recommend that the federal government establish minimum standards that states must use when selecting their benchmark plans.

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