Government Regulations Describe Minimum Benefits That Must Be Included in Most Health Plans

A major part of the Affordable Care Act (ACA) is the requirement that nongrandfathered health insurance plans offer an essential health benefits package that provides a comprehensive set of services. In February, the U.S. Department of Health and Human Services issued final regulations defining the services that must be included in most health plans, beginning in 2014.

What are essential health benefits?

Essential benefits appear in 10 broad 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; and pediatric services, including oral and vision care. The final rule also clarifies that insurers cannot charge patients a co-pay for a colonoscopy if a polyp is found and removed. Previously, consumers may not have paid for the screening, but would receive a charge for removing a polyp during the procedure.

Also starting in 2014, all types of health insurance plans will include an annual limit on out-of-pocket cost sharing for individuals and families. While the limits haven’t been set for 2014, a comparable limit for self-only coverage in 2013 is $6,250.

In addition, beginning in 2014, nongrandfathered plans must come within certain categories based on “actuarial value,” or the average share of total plan benefits covered by the plan. For example, if a plan has an actuarial value of 70%, a consumer can expect to be responsible for 30% of the costs of all covered plan benefits. The categories will be defined by four “metal levels.” Bronze plans will cover 60% of health-care costs; silver plans, 70%; gold plans, 80%; and platinum plans, 90%. The metal levels are intended to help consumers compare plans with similar levels of coverage.

Does it apply to all health plans?

These rules apply to nongrandfathered individual and small group health plans, as well as plans offered through state-based health Exchanges. Grandfathered plans, to which these requirements do not apply, include health plans created on or before March 23, 2010. However, some ACA provisions apply to all plans (i.e., grandfathered plans), including the prohibition from applying lifetime dollar limits to key health benefits, the requirement that plans can’t be cancelled except in cases where the applicant provided intentionally false information, and the extension of dependent coverage to adult children until age 26.


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