A set of health care service categories that must be covered by certain plans, starting in 2014.
The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services, known as essential health benefits.
Essential health benefits must include items and services within at least 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 (RX)
- rehabilitative and habilitative services and devices
- laboratory services
- preventive and wellness services and chronic disease management
- pediatric services, including oral and vision care.
Additional Coverages:
- Preventive Services covered at 100%
- No Lifetime Limits
- No Annual Limits on the Dollar Value of Essential Benefits
- Covered Without Cost Sharing
- Breastfeeding Support, Supplies, and Counseling
- Screening and Counseling for interpersonal and domestic violence
- Screening for gestational diabetes
- DNA testing for High Risk HPV
- Counseling Regarding Sexually transmitted infections including HIV
- Screening for HIV
- Contraceptive Methods and Counseling
- Well Woman Visits
Insurance policies must cover these benefits in order to be certified and offered on the Health Insurance Marketplace, and all Medicaid State plans must cover these services by 2014.
In addition, effective for plan years beginning Jan 1, 2014, a group health plan not in existence on March 23, 2010 , must provide coverage of certain costs of cliniclal trials, Thus a group health plan will not be allowed to:
- Deny (or limit or impose additional conditions on) the coverage of routine patient costs for items and services furnished in connection with participation in the trial; or
- Discrimination again the individual on the basis of he individual’s participation in a trial.
Cost Sharing and Deductible Limits
- Cost-sharing
includes any expenditure required by or on behalf of an enrollee with respect to EHB, such as deductibles, co-payments, co-insurance and similar charges. It excludes premiums and spending for non-covered services. Furthermore, a participant’s cost-sharing for out-of-network services is not counted in the cost-sharing limit for plans using provider networks.
ACA’s cost-sharing limit is tied to the out-of-pocket maximum for health savings account (HSA)-compatible high-deductible health plans (HDHPs). There are separate limits for self-only coverage and family coverage (other than self-only). Because these limits are adjusted annually for cost-of-living increases, the 2014 out-of-pocket maximums for HDHP coverage are not currently available. However, for 2013, the HDHP out-of-pocket maximum cannot exceed $6,250 for self-only coverage and $12,500 for family coverage. The IRS will publish out-of-pocket maximum limits for 2014 in Spring 2013. For plan years after 2014, HHS will increase the cost-sharing limits similar to increases in the annual deductible limit.
- Annual Deductible Limit
Beginning in 2014, the annual deductible for a health plan in the individual or small group market may not exceed $2,000 for self-only coverage and $4,000 for family coverage. For plans using provider networks, an enrollee’s cost-sharing for out-of-network benefits does not count toward the annual deductible limit. HHS will increase the annual deductible limits annually. This annual deductible limit applies only in the fully-insured individual and small group markets. Thus, the limit does not apply to HealthFlex, other self-insured annual conference plans or fully-insured annual conference plans in the large group market (large group plans typically cover more than 50 employees).
Preventive Services covered at 100%
No Lifetime Limits
No Annual Limits on the Dollar Value of Essential Benefits
- Covered Without Cost Sharing
- Breastfeeding Support, Supplies, and Counseling
- Screening and Counseling for interpersonal and domestic violence
- Screening for gestational diabetes
- DNA testing for High Risk HPV – Human PapillomaVirus
- Counseling Regarding Sexually transmitted infections including HIV – Human Immunodeficiency Virus
- Screening for HIV
- Contraceptive Methods and Counseling (FDA Approved)
- Well Woman Visits
