Affordable Care Act Study Indicates Vision Benefits Limited within States' Benchmark Plans


WASHINGTON, D.C.—An Urban Institute report showing how five states are providing the essential health benefits required by the Patient Protection and Affordable Care Act (ACA) indicates that health insurance plans in all but one of the five states had to add vision benefits to meet the standard. The report, Cross-Cutting Issues: Moving to High Quality, Adequate Coverage: State Implementation of New Essential Health Benefits Requirements, monitored how Alabama, Colorado, New Mexico, Oregon and Virginia are responding to the essential health benefits package requirements.

The ACA requires that plans sold through state health insurance exchanges provide ten essential health benefits, among them, “pediatric services, including oral and vision care.” Rather than define a uniform, national set of essential health benefits, the U.S. Department of Health and Human Services allowed each state to choose a benchmark plan on which to base their essential health benefits package. In selecting their benchmark, states were allowed to choose among 10 options—the largest health plan by enrollment in any of the three largest small-group insurance products in the state; any of the three largest state employee health benefit plans; any of the three largest plans offered to federal employees; and the largest commercial health maintenance organization plan in the state. If a state did not make a benchmark selection, it would default to the largest health plan offered in the largest small-group product in the state.

In the case of pediatric oral and vision services, states could choose to supplement their chosen benchmark plans with the benefits provided by the Federal Employee Dental and Vision Insurance Program Plan or a state Children’s Health Insurance Program plan.

The report found that coverage of certain benefits, including vision services, is often limited within the benchmark plans selected by these states. “All but one state had to add both the pediatric dental and vision benefits,” according to the study. While Alabama, New Mexico, Oregon and Virginia all had to add both pediatric dental and vision benefits to their benchmark plans, Colorado had to add only pediatric dental.

The report was written by Sabrina Corlette, Christine Monahan and Kevin W. Lucia of Georgetown University’s Health Policy Institute with support from the Robert Wood Johnson Foundation. It is one of a series of papers focusing on particular implementation issues in these case study states. The comprehensive monitoring and tracking to examine the effects of the ACA began in May 2011 and will take place over several years.