States Grapple With Including Infertility Treatments, Other Services Among Essential Health Benefits

October 5, 2012 — Whether insurers should have to cover infertility treatments is among states' considerations as they try to set the essential health benefits for their health insurance exchanges, the Washington Times reports. While health plans in Kansas' exchange will be required to include coverage for the treatments, plans in Arkansas and Colorado will not (Winfield Cunningham, Washington Times, 10/3).

Essential health benefits describe the minimum coverage that health plans will have to offer in selling policies through the state-based health insurance exchanges, which will launch in 2014 under the Affordable Care Act (PL 111-148). The law outlines 10 broad categories of coverage -- such as hospitalization, maternity care, prescription drugs and pediatrics -- that should be included.

Last year, HHS said it will allow states to decide which specific benefits they will require health plans to cover. States can choose one of four categories of health insurance plans as a benchmark: one of the state's three largest small-group plans; one of the state's three largest health plans for state employees; one of the three largest health plans offered under the Federal Employees Health Benefits Plan; or the largest HMO operating in the state's commercial market (Women's Health Policy Report, 6/12).

According to the Times, so far, 22 states and Washington, D.C., have decided which benefits plans must include. Many states are struggling to define whether certain services -- such as infertility treatments, massage therapy, weight-loss surgery and chiropractic care -- should be considered "essential."

States also have had trouble deciding how to incorporate certain services that are required by federal law, such as dental care for children, that have not been a traditional part of standard coverage. Some states have refused to set EHB rules until HHS offers more specific federal guidance (Washington Times, 10/3).