Essential Health Benefits

Other than the categories noted above, there is no information on what specific services are included. The Secretary of HHS will, in the future, define what constitutes "Essential Health Benefits". When making the determination, the Secretary shall ensure that the scope of the Essential Health Benefits is equal to the scope of benefits provided under a typical employer plan. To help make this determination, the Secretary of Labor shall conduct a survey of employer-sponsored coverage to determine the benefits typically covered by employers, including multiemployer plans, and provide a report on such survey to the Secretary of HHS.

A senior medical review team of UnitedHealthcare clinicians reviewed the general categories of Essential Health Benefits contained in the PPACA. The Essential Health Benefit categories were reviewed to determine how services/benefits should be categorized in the interim, pending definition by the Secretary of HHS. Using the outlined approach, UnitedHealthcare created three categories for Essential and Non-Essential Health Benefits: Essential, Non-Essential, and Mixed. These categories are outlined in the Essential Health Benefit Guides posted above under Essential health benefit Information section.

All services (essential or non essential) must meet all other requirements for coverage including any cost effective requirements and that the service or device must not be unproven, experimental or investigational. Individuals should review their coverage documents to determine the scope of services covered under their plan.

Some benefit categories contain services/devices that are a mix of Essential and Non-Essential Health Benefits. Subject to further regulatory guidance from HHS, benefit categories that were determined to contain both Essential Health Benefits and Non Essential Health Benefits depending upon if the specific service in question is rehabilitative or habilitative in nature. In this circumstance, UnitedHealthcare will retain any dollar limit that may be applied to the category and a review will take place once the dollar limit is exceeded. If the service/device is determined to be an Essential Health Benefit, it will be paid. If the benefit/device is determined to be a Non-Essential Health Benefit, the maximum will have been met and the claim will not be paid.

To reiterate, the categorization of a benefit as Essential or Non-Essential does not indicate that the benefit will or will not be covered under your plan. All services (essential or non essential) must meet all other requirements for coverage including any cost effective requirements and that the service or device must not be unproven, experimental or investigational.

Essential Health Benefits impact issues such as lifetime maximums and annual maximums for both fully insured and self insured plans.

For plan years beginning in 2010 the only requirement for "Essential Health Benefits" is that if they are included in the plan they may not be subject to a lifetime limit and until 2014 can only be subject to a "restricted annual limit".

The interim final regulations on lifetime/annual limits grant waiver authority to the Secretary of Health and Human Services regarding the lifetime / annual limits provision. For plan years that begin before January 1, 2014, the Secretary of Health and Human Services has established a plan under which the annual limits requirements may be waived (for a period specified by the Secretary) for a group health plan or health insurance coverage that has an annual dollar limit on benefits. The waiver may be granted if compliance with the restricted annual limits would result in a significant decrease in access to benefits under the plan or health insurance coverage, or would significantly increase premiums for the plan or health insurance coverage.

All PPACA changes regarding Essential Health Benefits will occur on the group's renewal on or after 9/23/10.