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."