It is among the health-care law's most important — and most daunting — questions: What health-care benefits are absolutely essential?
California legislators say acupuncture makes the cut. Michigan regulators would include chiropractic services. Oregon officials would leave both of those benefits on the cutting-room floor. Colorado has deemed pre-vacation visits to travel clinics necessary, while leaving costly fertility treatments out of its preliminary package.
Policy experts expected the Affordable Care Act to establish a basic set of health benefits for the nation, but the Obama administration instead empowered each state to devise its own list. When all Americans are required to purchase health insurance in 2014 or pay a penalty, they will find that the plans reflect the social and political priorities of wherever they live.
That nationwide patchwork highlights the difficulty of agreeing on what constitutes good basic health care, as well as the tricky balances that states face in weighing coverage vs. cost.
"I want a benefit package that gives people viable protection but not necessarily a Mercedes," said Arkansas Insurance Commissioner Jay Bradford, who is still deciding what options to pick for his state.
If insurance plans cover too much, premiums could become prohibitively expensive. But if they skimp on coverage, the states could fail to deliver on the health law's basic promise: extending quality health coverage to 30 million Americans.
States do have guidelines: They must cover 10 broad categories outlined in the Affordable Care Act, including doctor visits, maternity care and prescription drugs. They also must use an existing health-insurance policy as a template, such as a small-group plan or the package for state employees.
Eleven states have settled on packages of essential health benefits or are close to doing so, according to the consulting firm Avalere Health. Twenty others are still in the process of choosing a plan.