Time to Act on Essential Health Benefit Standards for Utah

The Essential Health Benefit (EHB) will be the package of benefits that must be offered by all insurance policies sold in the small group and individual markets beginning in 2014.  People who work for small businesses will be assured this package of benefits when they buy insurance.  People who buy their own insurance will also be assured this essential health benefits package.  The essential health benefit will be required both in and out of the new insurance market places, called “exchanges.”  In addition, the Medicaid program and the Basic Health Programs will have to cover, at a minimum, these essential health benefits.
The essential health benefits must not discriminate based on age, disability, or expected length of life, and must consider the health needs of diverse segments of the population.   EHB must cover the following 10 categories:
(1) ambulatory patient services
(2) emergency services
(3) hospitalization
(4) maternity and newborn care
(5) mental health and substance use disorder services, including behavioral health treatment
(6) prescription drugs
(7) rehabilitative and habilitative services (defined in the Social Security Act as “services designed to assist individuals in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and community based settings.”) and devices
(8) laboratory services
(9) preventive and wellness services and chronic disease management
(10) pediatric services, including oral and vision care.
Rep. Dunnigan, the co-chair of the Health System Reform Task Force, is proposing that the PEHP Basic plan be used as the EHB benchmark plan.  This means that Utah will build their EHB based on what is offered in the PEHP Basic plan. 
What we think:
Three of the 10 required categories (listed above) are deficient in the PEHP Basic plan. These three categories are: mental health and substance use disorder services, including behavioral health treatment; pediatric services, including oral and vision care; and rehabilitative and habilitative services and devices. Utah will have to substitute benefits from a different plan to make the benchmark complete.  Specifically, Utah would have to supplement the deficient category from another of the possible benchmarks approved by Federal Health and Human Services. 
Center for Consumer Information and Insurance Oversight (CCIIO) explains it like this:
“For example, if a benchmark plan covers newborn care but not maternity services, the State must supplement the benchmark to ensure coverage for maternity services.  The default benchmark plan would be supplemented by looking first to the second largest small group market benchmark plan, then to the third, and then, if neither of those small group market benchmark plans offers benefits in a missing category, to the FEHBP benchmark plan with the highest enrollment.” (
In addition, the EHB will have to comply with the Mental Health Parity and Addiction Equity Act (MHPAEA).  This means that mental health services have to be covered at the same level as physical health services.
What you can do:
You can read more about the EHB by visiting these websites:
Also see the background materials posted on the Task Force's website here:
Please attend the Health System Reform Task Force meeting on Thursday, August 16, 9AM, Room 30 House Bldg.  
NOTE: there will be time for public comment about the EHB. To comment, raise your hand high! If time is limited, please allow National Alliance on Mentally Illness (NAMI) and other knowledgeable consumer-friendly mental health groups to go first.
For the schedule of health policy-related interim committee meetings, click on Health Action Calendar here.

Utah Medicaid Coverage Coalition to Focus on Expansion Through 2012 

Governor Herbert and state legislative leaders are in no rush to implement the now optional Medicaid expansion. Knowing what a heavy lift it will be (click here to see Gov. Herbert’s recent editorial in the Washington Times) for Utah, a new coalition has formed to build the case.

Read more here.

Update on Behavioral Health Integration (BHI) Workgroup

by Jimmy Heffernan, UHPP intern

The Mental and Behavioral Health Integration Workgroup of the Health Reform Task Force has been meeting for the last few months to explore better ways to structure incentives for behavioral-physical health integration through payment and delivery system reforms for sake of better health and lower costs.

Read more here

Health Action Calendar

Health and Human Services Interim Committee (note topic: Medicaid—Promoting Wellness)
Wednesday, August 15, 2:00 PM
Room 20 House Building at the State Capitol Complex

Health System Reform Task Force Meeting (and workgroups to follow)
Thursday, August 16, 9AM-12PM
Room 30 House building at the State Capitol Complex

UHPP Monthly Meeting with Michael Hales (Topic: the Draft ACO Contracts)
Wednesday, September 5th 1:30-3:00 PM
Utah Department of Human Services, Room 2026 (capacity is limited)
Address: 195 North 1950 West
RSVP:  to
Medicaid Coverage Coalition Full Meeting
Thursday, September 6th at 3:00-4:30 PM
United Way of Salt Lake, 257 E. 200 S. Suite 300 (note new location!)

Accountable Care Draft Contract Language Released for Input

The draft contract language is out for public discussion and negotiation, thanks to a SL Tribune GRAMMA request.  

Read more here

Take Care Utah Website Goes Live!

Take Care Utah is happy to announce that our website is LIVE and fully loaded with tools and information to help partner agencies provide effective enrollment and navigation assistance, including our Tool Kits for community-based organizations and schools. 

Read more here

Toolkit Training

Take Care Utah would like to thank everyone that came to the Tool Kit Training we had on the 31st of July.  We are truly inspired by the number of people and organizations that want to help enroll families in affordable health insurance. 

Read more here.

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