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Essential Health Benefits

Update: The comment period for the 2017 plan has closed. Read more about Pennsylvania's recommendation for the 2017 Essential Health Benefits Benchmark plan here

Two of Governor Tom Wolf’s priorities are that his administration be open and transparent and that it work to make health care more accessible to Pennsylvanians across the Commonwealth.

To further those goals, I am asking for your input as the state considers an important recommendation to the federal government that can help shape our health care future.

The Affordable Care Act (ACA) requires that individual and small group health care plans cover a set of services, which are known as “essential health benefits” (EHB). These benefit packages must include specific coverages, including ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vison care.

Because the state did not choose a package for consumers back in 2012, Pennsylvania’s current plan was selected for us by the federal government. The current benchmark plan may be viewed here. However, looking forward to 2017, we now we have the chance to make a collective choice that best fits families and consumers throughout the state.

If Pennsylvania does not make a recommendation, the federal government will once again select our benchmark plan. In this case, our package would be the Keystone Health Plan East option.

Essential Health Benefit Benchmark Plan Options

With that in mind, below are the options that we have to choose from:

The three largest plans by enrollment in any small group insurance product in Pennsylvania’s market:

The largest three state health benefit plans by enrollment. These three plans all have the same benefit package, although coverage limits differ on a few services between the PPO/CDHP plan design and the HMO plan design. Because both PPO and HMO plans are in the three largest plans by enrollment, please consider both plan designs:

The largest three national health benefit program plans:

The largest commercial non-Medicaid HMO operating in Pennsylvania:

Essential Health Benefit Benchmark Plan Pediatric, Dental, and Vision Supplementary Options

If the selected benchmark plan does not cover pediatric oral services, the benchmark plan must be supplemented by the FEDVIP (federal employees') dental plan with the largest national enrollment or the Title XXI CHIP plan in Pennsylvania with the larges enrollment. These two plans are:

If the selected benchmark plan does not cover pediatric vision services, the benchmark plan must be supplemented by the FEDVIP (federal employees') vision plan with the largest national enrollment or the Title XXI CHIP plan in Pennsylvania with the largest enrollment. These two plans are:

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Essential Health Benefit Benchmark Plan Options Comparison Chart

To assist in review and comparison of these options, the Pennsylvania Insurance Department prepared a chart that presents a preliminary summary overview of the benefits available under the current benchmark plan and the options for the new benchmark plan. Note that this chart is not a substitute for the complete plan materials; it does not reflect a complete list of every benefit, benefit limit, or other service limit that may be included in any of the plans. This summary should not be relied on in place of your own analysis of the plan materials, and you should reference the plan documents for exact details of each plan.

Invitation for Comment

In order to assist us in evaluating these plans and developing a recommendation, we invite public comment on all these options. These comments may consider, for each plan’s benefit package, things like: the impact on particular populations, including vulnerable citizens; the flexibility and innovation in plan design by different insurance companies that may be lost or gained, and the potential cost of going with a specific option. We particularly invite comment on the habilitative benefits available in the benchmark plan options and solicit comments on a possible state definition of habilitative services in the event that the selected benchmark plan does not include habilitative services



use the federal government requires Pennsylvania’s recommended selection by July 1, 2015, the comment period will only remain open until June 12th. We invite you to send your comments to

Thank you again for your help in shaping Pennsylvania’s health care future.

Teresa Miller
Insurance Commissioner