Essential Health Benefits
Understand what plans must cover these health benefits, and how various plans are impacted by respective cost sharing limits and rules.
With health care reform, fully insured small group and individual health plans on and off the Exchange/Marketplace must cover essential health benefits beginning January 1, 2014. The Department of Health and Human Services (HHS) stated that its aim is to balance comprehensiveness, affordability and state flexibility in the development of Essential Health Benefits (EHB).
To support fulfilling this aim, HHS instructed each state to select an existing health plan as a "benchmark" to establish the services and items included in the Essential Health Benefits package for 2014 and 2015. States chose from one of four health insurance plan options as a benchmark:
- the largest plan based on enrollment in any of the three largest small group products in the state
- any one of the three largest state employee health plans
- any one of the three largest federal employee health plan options
- the largest HMO plan offered in the state’s commercial market
The default for states that chose not to set a benchmark is the small group plan with the largest enrollment in the state. For 2016 and beyond, HHS will reassess the proposed benchmark process.
Please note that the states define “small group.” Currently, groups with up to 50 employees are classified as small group. In 2014, some states may raise the limit to 100. In 2016, the standard for small group will be the national definition of 1-100 employees.
Essential health benefits under the Patient Protection and Affordable Care Act will include the following general categories:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance abuse 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
Effective July 16, 2014, required coverage of Essential Health Benefits no longer applies to insured small group and individual plans issued in the U.S. territories (Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa and the Northern Mariana Islands).
Read the most recent guidance on Essential Health Benefits and related rules:
More on Reform
EMPLOYER MANDATE IN REFORM
Businesses must offer affordable medical insurance that provides “minimum value” to employees and their dependents.
Public Marketplaces/ Exchanges
Marketplaces are the government run online shopping hubs for health insurance, available in every state.
INDIVIDUAL MANDATE IN REFORM
Under the health care reform law, all people must have minimum essential coverage beginning January 1, 2014.