March 20, 2013

10 essential benefits that must be covered under Obamacare

In keeping with the ongoing march toward Affordable Care Act compliance in 2014, I wanted to share that the Department of Health and Human Services (HHS) has recently issued several important pieces of guidance, including final standards related to essential health benefits, actuarial value, and accreditation.

In this post, I will discuss the different benefit categories that essential health benefit (EHB) packages must cover under the new standards.

To begin, non-grandfathered plans in the individual and small group markets issued both in and outside of an exchange’s “marketplace,” must cover EHB packages beginning in 2014.

Self-insured group health plans, health insurance coverage offered in the large group market, and grandfathered health plans are not required to cover the essential health benefits.

However, to the extent that self-funded plans and large insured plans offered outside the marketplace offer EHBs, whether grandfathered or not, these essential benefits cannot be subject to annual and lifetime limits.

Coverage for the EHB package must cover 10 specific categories of benefits:

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

What should an employer do now to prepare for these changes?
If your plan will be subject to the essential health benefits rules, be aware that plan changes to comply with this requirement may be necessary. Your insurer should notify you about any policy modification. Even If your plan is not subject to the EHB requirement, be aware of the essential health benefits offered by the plan and make certain no annual or lifetime limits are imposed on these benefits.

Please be sure to check back to the blog for more updates relating to the Affordable Care Act in 2014.

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