Which drugs are 'essential benefits'? Depends on the state

Report finds significant variation in drug coverage requirements

Required coverage of prescription drugs will vary nationwide because states have set significantly different requirements for minimum essential health benefits (EHB) that health plans must provide under the Affordable Care Act (ACA), according to a new report from Avalere Health.

  • What do your 30 million new patients have in common? When the insurance exchanges come online in 2014, the exchanges will expand coverage to millions of new individuals. How will these new patients affect your hospital's margins? Read more.

Under the ACA, health plans in state health insurance exchanges must provide coverage for 10 broad categories of benefits, such as maternity care, prescription drugs, and preventive care.

In guidelines released last year, HHS said states could use one of four types of health insurance plans as a benchmark and the benefits provided by that plan would be designated as essential benefits. All other plans in the exchange would be required to provide benefits of equal or greater value.

According to Avalere's analysis of states' EHB benchmark plans, the range of prescription drugs covered in states varies widely, from as little as 45% of available drugs in some states to as much as 99% in other states.

Some states will require health plans to cover all available FDA-approved drugs, while others will require coverage for only about half of such medications, Avalere found.

Arizona, Connecticut, New Hampshire, and Virginia are among the states with the most generous coverage, while California, Maryland, Michigan, and Wisconsin are among the least generous, as they have benchmark plans that cover 45% to 76% of available drugs (Baker, "Healthwatch," The Hill, 12/4; AP/Washington Times, 12/4).


Next in the Daily Briefing

Executive transitions

Read now