New Affordable Care Act Regulations on Essential Health Benefits
On November 20, 2012 the U.S. Department of Health and Human Services (HHS) released new rules regarding the implementation of the Affordable Care Act (ACA), which include regulations addressing essential health benefits. The ACA regulations help consumers shop for and compare non-grandfathered private health insurance options by promoting consistency across plans and ensuring that plans cover a core group of items and services. Specifically, the regulations set out standards related to the coverage of essential health benefits while still providing flexibility to states to shape how these are defined.
Starting on January 1, 2014, plans must include as essential health benefits or services items in the following 10 categories:
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
Essential health benefits must be equal to those offered by a “typical employer plan.” Essential health benefits will be based on a state specific benchmark plan, including the largest small group health plan in the state. To set the benchmark plan a state would be required to select a plan from among several options identified in the regulation. Thereafter, all plans must offer essential health benefits substantially equal to those established in the benchmark plan.
For more information about essential health benefits, please contact your Trust Fund counsel.
Author: Conchita Lozano-Batista
