How these mandates are structured also differ substantially. For example, they can be legislated to affect the benefits that different types of insurance markets (small- or large-group plans or the individual market) must cover, what they must offer to sell (but not necessarily cover), the type of plan that is included (e.g., health maintenance organizations [HMOs]), the target populations for the service, and the periodicity of the service. Many, but not all, of these benefits are now covered under the new ACA preventive coverage rules without any cost sharing. Nevertheless, the ACA preventive care rules do not supersede state requirements. This means that for states that have coverage mandates for preventive services that are broader than the list of services required to be covered by Section 2713 of the ACA, insurance plans that sell policies in those states must still offer coverage for those services, in addition to the services required by the ACA.3

Although many states have coverage mandates or specific benefit requirements, 12 states have also required plans that sell on the individual and small-group markets to offer standardized benefit packages (KFF, 2009b). These standardized policies generally include a class of services and outline cost-sharing requirements. They were intended to facilitate the comparison of different plans for consumers and to make it harder for insurers to design benefit packages that are attractive to healthy individuals and avoid drawing those with health problems. In most states, insurers must offer the standardized plans but can also sell other types of plans (KFF, 2009b).

The benefit package that the commonwealth of Massachusetts requires, however, is a notable exception and does provide detailed coverage information. In 2006, the commonwealth of Massachusetts passed Chapter 58, the health reform law. This law combines the concept of individual responsibility through an individual mandate, which requires that individuals purchase health insurance that meets minimum standards developed by the state (creditable coverage). To ensure affordability, however, government subsidies are provided. This law created multiple public and private health insurance pathways and initiated a system of shared responsibility among the stakeholders in health care provision. Chapter 58 also created a health insurance exchange, known as the Commonwealth Connector, to make health coverage available to residents and to regulate the insurance products offered through the exchange to ensure that individuals have minimum creditable coverage. The reforms enacted by the commonwealth of Massachusetts served as a model for the ACA.

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3 When the federal subsidies for individuals to purchase coverage through the insurance exchanges become available, the costs of any benefits mandated by the states that exceed those specified in federal law will have to be funded by the states for those receiving subsidies. Given this new cost, it is possible that some states will eliminate these mandated benefits, at least in the individual market.



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