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HHS issues essential benefits for ACA coverage

Wednesday February 20, 2013
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The U.S. Department of Health and Human Services has released policies pertaining to essential health benefits, the core package of benefits that insurers must offer to individuals and small groups when the Affordable Care Act takes full effect in 2014.

One goal of the package of essential health benefits is to expand coverage of mental health and substance use disorder services, including behavioral health treatment, for millions of Americans, according to HHS.

In the past, according to an HHS news release, nearly 20% of individuals purchasing insurance did not have access to mental health services and nearly a third had no coverage for substance use disorder services.

HHS seeks to expand coverage of these services by including mental health and substance use disorder benefits as essential health benefits; by applying federal parity protections to mental health and substance use disorder benefits in the individual and small-group markets; and by providing more Americans with access to quality healthcare that includes coverage for mental health and substance use disorder services.

By law, essential benefits must include items and services in mental health and substance use disorder services, including behavioral health treatment, and at least nine other categories: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services that include oral and vision care.

All plans subject to EHB must offer benefits substantially equal to the benefits offered by a designated benchmark plan. States can select a benchmark plan from among several options, including the largest small-group private health insurance plan by enrollment in the state. This approach strikes a balance between comprehensiveness, affordability and state flexibility, according to HHS. The final rule also gives issuers the flexibility to offer innovative benefit designs and a choice of health plans.

The regulations concerning essential health benefits apply to plans for individuals and small groups, and to people seeking to obtain coverage under the expanded eligibility criteria for Medicaid.

The final rule additionally outlines actuarial value levels in the individual and small group markets, which helps to distinguish health plans offering different levels of coverage. Beginning in 2014, plans that cover essential health benefits must cover a certain percentage of costs according to the following system: 60% for a designated bronze plan, 70% for a silver plan, 80% for a gold plan and 90% for a platinum plan.

These designations will allow consumers to compare insurance plans with similar levels of coverage and cost-sharing based on premiums, provider networks and other factors. In addition, the ACA limits the annual amount of cost-sharing that individuals will pay across all health plans in an effort to prevent insured Americans from facing catastrophic costs associated with an illness or injury.

The provisions are designed to help consumers compare and select health plans in the individual and small group markets based on what is important to them and their families. People can make these choices knowing these health plans will cover a core set of critical benefits and can more easily compare the level of coverage based on a uniform standard, according to HHS.

"People all across the country will soon find it easier to compare and enroll in health plans with better coverage, greater quality and new benefits," HHS Secretary Kathleen Sebelius said in a news release.

More about the final rule and package of essential health benefits is available in a fact sheet at http://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.html.


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