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Blog by: Jeanne Hines, SPHR

Whether you’re a fan of the Affordable Care Act (ACA) or not, one of the sensible things it has done is to require most health plans to offer uniform benefits.   This will lighten the burden of knowing what services one can expect to receive from their health plan.

Beginning in 2014, the ACA requires non-grandfathered plans in the individual and small group markets to offer a comprehensive package of items and services, known as essential health benefits (EHBs). This requirement applies to plans offered inside and outside of the state insurance Marketplaces (Exchanges), which are scheduled to become effective in 2014.

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

ACA requires EHBs to reflect the scope of benefits covered by a typical employer plan and to cover at least 10 general categories of items and services.   Under the ACA, states are allowed to select their own benchmarks for defining EHGs, however, they must include items and services within at least the following 10 categories:

  • Ambulatory patient services(outpatient care you get without being admitted to a hospital);
  • Emergency services;
  • Hospitalization (such as surgery);
  • Maternity and newborn care
  • Mental health and substance use disorder benefits, including behavioral health treatment (this includes counseling and psychotherapy);
  • Prescription drugs;
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities or chronic conditions gain or recover mental or physical skills);
  • Laboratory services;
  • Preventive and wellness servivces and chronic disease management; and
  • Pediatric services, including oral and vision care.

For more specifics in your state, visit the web page of the National Conference of State Legislatures where you’ll find a link to a US map indicating essential benefits by state.  The home page address is:  http://www.ncsl.org/.

The ACA requires Marketplaces, or Exchanges, to offer at least four plans with varying levels of coverage.  The plans will determine the amount of payment toward the above-named benefits.  Next time, we’ll take a look at the four levels, called “metal levels” and what they mean.



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