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State Sets Minimum Benefits For Health Plans

Californians now have a clearer picture of what health insurance will look like when major provisions of the federal health care law debut in 2014.

Acupuncture to treat pain and nausea will be covered, for example, as will tobacco cessation and vision screening.

But the jury’s still out on chiropractic care.


State lawmakers this week sent two bills to the governor that identify the services health insurance plans must cover starting in 2014 for individuals and small businesses.

The measures – SB 951 by Sen. Ed Hernandez and AB 1453 by Assemblyman Bill Monning – define what are called “essential health benefits” under the federal health care overhaul and will fundamentally transform the kind of insurance Californians will buy.

“It’s historic,” said Monning, D-Carmel. The bills, he said, will affect “the millions of Californians who have had limited coverage or no coverage who now will have access to coverage, and it will be comprehensive in nature. It will include preventive services, immunizations, hospitalization. The list goes on and on.”

The benefits will apply to insurance plans sold through the state’s new health insurance exchange, which will offer federally subsidized plans for individuals and families making between 138 and 400 percent of the federal poverty level.

Unsubsidized plans sold outside of the exchange also must meet these requirements.


Insurance offered by large employers – initially those with more than 50 workers – does not have to meet these requirements, though many such plans already do.

The federal government has required that essential health benefits include services within 10 broad categories, such as “maternity and newborn care” and “prescription drugs.”

It gave states the flexibility to refine those broad categories by choosing an existing health care plan that will serve as a benchmark come 2014. In essence, the benefits and services in that benchmark plan will make up the state’s essential health benefits.

In California, the Hernandez and Monning bills identify the benchmark plan as the Kaiser Small Group HMO 30 plan.

“While we didn’t advocate necessarily for a Kaiser plan to be the benchmark, we certainly are pleased,” said Chris Stenrud, executive director of advocacy and public affairs for Kaiser Permanente.

He said Kaiser has offered this type of plan for decades and has historically covered services that some of its competitors have not, such as maternity care.

“From our perspective, it’s bringing the rest of the market to a more complete package of health benefits,” he said.

Hernandez, D-West Covina, agreed that the bills will bring consistency to the health insurance marketplace, giving consumers power to make educated choices.

“This is the floor. Anyone can buy products that have more, which I’m assuming will cost more,” he said. But “everyone will know that if they purchase a product inside or outside the exchange, they will get all the essential benefits and will be covered.”

Health advocates expressed support for the essential health benefits package, but say some critical services will remain uncovered.

“We’re really excited to see the addition of mental health and substance abuse treatment. Those are services that have been left out” in the past, said Cary Sanders, director of policy analysis for the California Pan-Ethnic Health Network.

But, while vision and dental benefits for children will be covered, the federal guidelines don't require that coverage for adults, she said. “We didn’t get everything we wanted, but it’s a very good first step,” she said.

California could require insurance companies to cover additional benefits beyond those required by the federal government, Monning said, but if it does, it must pick up the tab.

This is where the question of chiropractic care comes in. At this point, it doesn’t look like it will be part of the essential health benefits, he said.

California is still waiting for a final answer from the federal government, but if the state wants to mandate chiropractic care on its own, “we would have to defray that additional cost” for people buying subsidized insurance through the exchange, he said.

That’s not likely.

“With our own budget challenges in California, the prospect of getting basically a two-thirds vote to generate the resources from our general fund to cover a mandate not covered by the essential health benefits would be a heavy lift,” Monning said.

Corrected: July 17, 2024 at 9:00 AM PDT
The California HealthCare Foundation Center for Health Reporting does in-depth reporting on California health issues. Located at the USC Annenberg School for Journalism & Communication, the center is funded by the nonpartisan California HealthCare Foundation.