Governor Cautiously Optimistic About More PPACA Flexibility


Ten days ago Governor Gary R. Herbert and other state leaders sent Kathleen Sebelius, head of the U.S. Dept. of Health and Human Services (HHS), a letter urging consideration of state input in federal health policy, as well as flexibility in defining the “essential health benefits” package dictated by the Patient Protection and Affordable Care Act (PPACA). Last Friday, HHS released a bulleting doing just that.

“The HHS announcement is not only good news for states. It’s also good news for consumers, providers and business,” said Governor Herbert. “The states are clearly the right place for such decisions to be made. But let me be clear, we need to proceed cautiously as we determine the best approach for the people of Utah. Therefore, we are reviewing the details in the announcement so that we clearly understand its ramifications.”

The HHS bulletin outlined proposed policies to implement a PPACA provision requiring health insurance plans offered in the individual and small group markets, both inside and outside of the State’s Health Insurance Exchange, to offer a comprehensive package of items and services, known as essential health benefits.

“Greater certainty and greater flexibility are unquestionably preferable for consumers. As we approach 2014 and the implementation of PPACA, Utah must continue to push for more certainty and flexibility in order to maximize access, expand options and keep costs down,” the Governor added.

Under the HHS approach announced Friday, states will have the flexibility to select a benchmark plan that reflects the scope of services offered by a “typical employer plan.” From four benchmark options, states will then select a plan to best meet the citizen needs. Those four options include:

  • One of the three largest small group plans in the State by enrollment;
  • One of the three largest State employee health plans by enrollment;
  • One of the three largest federal employee health plan options by enrollment;
  • The largest HMO plan offered in the State’s commercial market by enrollment.

If States choose not to select a benchmark, HHS intends to propose that the default benchmark will be the small group plan with the largest enrollment in the State.

HHS specifies ten categories for essential health benefits. They include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and pediatric services, including oral and vision care.

scroll to top