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.
While benefits for hospital care and doctor visits tend to look similar, coverage for alternative medicine and mental health services varies widely.
Virginia has edged close to selecting a plan. A Virginia advisory board recommended that the state adopt a plan that includes speech therapy and chiropractic care.
Some states have struggled to reach consensus on what counts as essential care. After debate, the California legislature settled on a benefit package that required insurance companies to cover acupuncture.
"There was strong support for inclusion of acupuncture in the treatment of pain management," said California Assemblyman Bill Monning, a Democrat who chairs the State Assembly's committee on health. "We were trying to find the most comprehensive plan and this is one element that helps us achieve that goal."
Other states have forgone such treatments in favor of ensuring affordable premiums. Oregon looked at benefits for acupuncture, chiropractic services and fertility treatment, areas where there is wide variation among insurance coverage. It heard from advocacy groups making the case for why these services are necessary. In its final package, none made the cut.
"This being Oregon, where you have a school of chiropractic care, there was a lot of discussion about alternative medicine," said Jeanene Smith, administrator of the Office for Oregon Health Policy and Research. "We felt that there was some benefit, but we didn't exactly consider these to be absolutely essential."
Oregon also rejected coverage for bariatric surgery, a range of stomach-reduction procedures that some other states have included, opting to emphasize obesity prevention instead of treatment.
For some small medical associations, these state-level debates have become crucial.
"It's a very big issue for us," said John Falardeau, senior vice president for government relations at the American Chiropractic Association. "We've been working hard with our state associations to make sure they're at these meetings, to even get on the essential benefit advisory board."
The chiropractors did succeed in securing a seat on the advisory board weighing Maryland's essential health benefits. In California, however, they ran into trouble when the legislature passed a benefit package that may exclude chiropractors from delivering services.
Some states are still debating whether they want to set a benchmark package at all. If they do not, the federal government will default to the benefits of the largest insurance plan in the state's small-group market.
Kansas Gov. Sam Brownback has decided against defining his state benefit package as his administration has decided not to "make any decisions regarding the implementation of the Obamacare until after the November elections," according to spokeswoman Sherriene Jones-Sontag.
It is less clear what happens if a state passes a benefit package that does not provide adequate coverage of the 10 categories outlined in federal law.
Utah has alarmed some advocacy groups by approving a plan that does not appear to specify a substance abuse benefit, even though the federal law requires one.
They have also questioned whether Utah's dental benefit, beginning coverage at age 3, will meet the federal mandate to provide pediatric dental coverage.
"Our concerns could be allayed if the federal government takes a strong position and pushes back about how they'll treat these," said Lincoln Nehring, a senior health policy analyst at Voices for Utah Children. "Since there's some uncertainty about how they'll treat these, that does cause us a fair amount of angst."