Essential Benefits

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Here’s the list of benefits that must be covered in all individual and small group plans.

Overview

The Affordable Care Act ensures Americans have access to quality, affordable health insurance. To achieve this goal, the law ensures that health plans offered in the individual and small group markets, both inside and outside of Health Insurance Marketplaces, offer a core package of items and services, known as “essential health benefits.” Under the statute, EHB must include items and services within at least the following 10 categories:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

The Affordable Care Act also directs that EHB be equal in scope to benefits offered by a “typical employer plan.” To meet this requirement in every state, the final rule defines EHB based on a state-specific benchmark plan. States can select a benchmark plan from among several options, including the largest small group private health insurance plan by enrollment in the state. The final rule provides that all plans subject to EHB offer benefits substantially equal to the benefits offered by the benchmark plan. This approach best strikes the balance between comprehensiveness, affordability, and state flexibility. The final rule also gives issuers the flexibility to offer innovative benefit designs and a choice of health plans.

Source: Essential Benefits Fact Sheet, February 20, 2013

Regulations and Guidance

HHS Final Regulation
Group Health Plans and Health Insurance Issuers Relating to Dependent Coverage of Children to Age 26 Under the Patient Protection and Affordable Care Act; Interim Final Rule and Proposed Rule (2/25/2013)
Fact Sheet: Essential Health Benefits Standards: Ensuring Quality, Affordable Coverage
Fact sheet about the February 20, 2013 final rule released by HHS that helps consumers shop for and compare health insurance options in the individual and small group markets by promoting consistency across plans, protecting consumers by ensuring that plans cover a core package of items that are equal in scope to benefits offered by a typical employer plan, and limiting their out of pocket expenses. (02/20/2013)
HHS Proposed Regulation
Young Adults and the Affordable Care Act: Protecting Young Adults and Eliminating Burdens on Businesses and Families (11/26/2012)
HHS Frequently Asked Questions on the Essential Health Benefits Bulletin
On December 16, 2011, the Department of Health and Human Services (HHS) released a Bulletin describing the approach it intends to take in future rulemaking to define the essential health benefits (EHB) under the Affordable Care Act. This document is intended to provide additional guidance on HHS’s intended approach to defining EHB. (2/17/2012)
HHS Essential Health Benefits Bulletin
The purpose of this bulletin is to provide information and solicit comments on the regulatory approach that the Department of Health and Human Services (HHS) plans to propose to define essential health benefits (EHB) under section 1302 of the Affordable Care Act. (12/16/2011)

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