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Essential Health Benefits

Timeline of Provisions

Essential Health Benefits

Summary

The Act defines certain categories of benefits as "Essential Health Benefits." The categories of essential health benefits are:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care

For More Information

Frequently Asked Questions

Does the Essential Health Benefits (EHB) package become effective across the board on January 1, 2014?

No. The EHB requirements become effective for each plan on the first day of the first plan year beginning on or after January 1, 2014. They apply only in the fully insured Individual and Small Group markets, with grandfathered plans excluded.

Will EHBs vary based on the type of health plan product?

No. Fully insured Individual and Small Group plans that must have EHBs in 2014 include all products, whether it is an HMO, PPO, POS or high-deductible HRA/HSA.

What are the deductible caps for Small Group plans under the Affordable Care Act?

The Affordable Care Act of 2010 (ACA) establishes limits on deductibles for fully insured, non-grandfathered plans in the Small Group market at $2,000 for individuals and $4,000 for families. These limits will apply to the plan on the first day of the first plan year beginning on or after January 1, 2014. These dollar amounts will be indexed for inflation each year. This requirement does not apply to grandfathered plans. The deductible ceiling applies only to fully insured Small Group plans. It does not apply to ASO plans or fully insured Large Group plans. For plans with network benefits, the limits apply only to the in-network deductible.

What are the out-of-pocket maximum limits under the ACA?

The ACA establishes limits on out-of-pocket maximums for non-grandfathered plans in the Individual, Small Group and Large Group markets. As with the deductible limits, the out-of-pocket limits will apply to the plan on the first day of the first plan year beginning on or after January 1, 2014. Out-of-pocket maximums may not exceed the limitations imposed on HSA-qualified high-deductible health plans ($6,350/single, $12,700/family for 2014). In addition, all member cost-sharing must apply to the out-of-pocket maximum (e.g., copayments and deductibles). For plans with network benefits, the limits apply only to the in-network out-of-pocket maximum. This requirement does not apply to grandfathered plans.

When will we know about the pricing impact of the EHB requirements on health plans?

The pricing impact is uncertain as we await more definition on how the 50 states select benchmark plans that will establish the scope of EHB packages for a "typical employer plan." We also need more guidance on the four "metallic" tiers of coverage that will be required in and out of Exchanges.

Habilitative services are listed along with rehabilitative services and devices. What is the difference?

A habilitative service is a health service that allows a patient to acquire a functional skill that should be present but is absent due to sickness or injury. Example: speech therapy for a non-verbal child with autism.

A rehabilitative service is a health service that allows a patient to reacquire a functional skill that was previously present but has been lost due to sickness or injury: Example: speech therapy for an adult who has suffered a stroke.

In the Employer Mandate, do the employees who count against the 50-person limit all have to be full-time employees?

No. An employer with at least 50 full-time employees or a combination of full-time and part-time employees that results in at least 50 full-time equivalents will be subject to the shared-responsibility provisions to provide minimum essential coverage for full-time employees and their dependents. This means that in determining whether an employer is an "applicable large employer," the employer must count all full-time employees and also count up (and average) all part-time employee hours. The mandate to provide coverage, however, only applies to the full-time employees (and their dependents) averaging 30 hours/week or more.

Are there any limitations on the waiting period before new hires can obtain health coverage?

In group markets of all sizes and funding, a maximum waiting period of 90 days will take effect on Jan. 1, 2014.

Will health plans have to exactly match the state-designated benchmark plans in terms of covered benefits?

No. Plans may have coverage that differs from the benchmark plan as long as covered benefits remain "substantially equal" and actuarially equivalent to those contained in the state EHB package.

Are there any EHB requirements specifically related to prescription drugs?

In order to meet the EHB requirements, a health plan must cover the greater of one drug in every category or class, or the same number of drugs in each category and class as the EHB benchmark plan.