Back To Articles

Keystone Health Plan East Selected as State’s Essential Health Benefits Benchmark Plan

July 7, 2015

The Pennsylvania Department of Insurance recently announced that Keystone Health Plan East will function as the state’s new Essential Health Benefits benchmark plan for 2017.

By Emily A. Eckert, Community Health Organizer


Under the Affordable Care Act, all health plans available on the Health Insurance Marketplace must include certain essential health benefits equal in scope to the services covered under a typical employer-based health plan. The list of essential health benefits includes: ambulatory services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services including mental health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services; and pediatric services including dental and vision care. 

Despite the regulation that these essential benefits be covered, the list of services enrollees receive varies greatly from state to state. This is a result of the Department of Health and Human Services (DHHS) granting states the power to choose a benchmark plan for their enrollees. 

In 2011 the state of Pennsylvania elected to have the Federal government assign a benchmark plan based on overall enrollment numbers in small-group plans. By opting out of plan selection, the state allowed DHHS to assign a plan based merely on numbers, not on actual health care needs and health priorities. The benchmark became an Aetna Health Maintenance Organization (HMO), with considerable benefit limits on habilitation services, substance use disorder (SUD) treatments, infertility treatments, and medical devices for hearing-impaired individuals. 

DHHS decided to allow states to select a new benchmark plan for the 2017 enrollment year, allowing states to re-evaluate their health priorities. “The selection of a new EHB Benchmark Plan for Pennsylvania is an important moment to evaluate our state’s systems,” said Antoinette Kraus, Director of the Pennsylvania Health Access Network. “It’s also an opportunity to set a broader framework to facilitate meaningful consumer and stakeholder engagement in the department’s ongoing work to see that the plans available to Pennsylvanians are providing clear, consistent information on benefits, complying with applicable state and federal laws governing benefit structures and protecting vulnerable populations, and (while outside the scope of this EHB selection process), charging rates that are not excessive, arbitrary or unfairly discriminatory.”

The Pennsylvania Health Access Network is pleased with the Department of Insurance’s decision to select Keystone Health Plan East as the new Essential Health Benefits benchmark plan. Keystone offers comprehensive and accessible health services across the list of essential health benefits, but PHAN also acknowledges that the new benchmark plan does not adequately address habilitative services.  

Moving forward, Pennsylvania must adopt the federal definition of habilitative services in order to meet the needs of more Pennsylvanians. PHAN recommends going further than the Federal definition to cover even more programs and services. In addition, the Department of Insurance should monitor plans to ensure that habilitative services are clearly defined and that the coverage is meeting enrollees’ needs. Supplementing habilitative services in the state’s benchmark plan will not be treated as a mandate separate from the pre-existing list of Essential Health Benefits; Pennsylvania will not have to defray the cost for any additional state benefit mandates related to habilitative services.  

You can find PHAN’s recommendations to the Department of Insurance on the EHB here

If you or someone you know has any questions about the new benchmark plan, please contact the Pennsylvania Health Access Network at (877) 570-3642. 

Emily A. Eckert is a Community Health Organizer and Certified Navigator at the Pennsylvania Health Access Network.