HHS Issues Final Rule on PPACA's Essential Health Benefits
Starting Jan. 1, 2014, under the Patient Protection and Affordable Care Act, health insurers will have to cover essential health benefits in the individual and small group plans sold on the health insurance marketplaces. Benefits will also apply to people who qualify for Medicaid under the health law's Medicaid expansion.
EHB include items and services in 10 specific categories:
• Ambulatory patient services
• Emergency services
• Maternity and newborn care
• Mental health and substance use disorder services, including behaviorial health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Lab services
• Preventive/wellness services and chronic disease management
• Pediatric services, including oral and vision care
However, states will have flexibility in determining how much coverage of EHB will be required. States can choose benchmark plans from options in their markets that are "equal in scope to a typical employer plan.
The final rule also outlined actuarial values, or "metal levels," of health plans that will offer EHB. When the health plans go live in 2014 on the insurance marketplaces, they must cover a certain percentage of the costs. These values are outlined in four metal tiers: bronze, silver, gold and platinum.
Bronze plans have an actuarial value of 60 percent, silver plans 70 percent, gold plans 80 percent and platinum plans 90 percent. This means that individuals who choose a bronze plan, for example, would be expected to pay 40 percent of their healthcare through deductibles, copays and other cost-sharing features, while the health insurer covers 60 percent.
Today's final rule finalizes many of the Obama administration's policies that were originally proposed in November.
To read the entire 149-page final rule, click here (pdf).
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