Essential Health Benefits

04-11-2014

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What Are the "Essential Health Benefits"?

Overview

The Affordable Care Act ("ACA" and also frequently referred to as "Obamacare") requires health plans to cover certain categories of benefits. These categories are described as "essential health benefits." Beginning in 2014 individual and small group plans will have to include essential health benefits unless the plan qualifies as grandfathered.

Section 1302 of the Affordable Care Act requires health plans to provide coverage for at least the following categories:

  • Ambulatory patient services: These include outpatient services such as doctor visits.
  • Emergency services: These include care received in an Emergency Room
  • Hospitalization: These include medically-necessary surgeries and other inpatient procedures
  • Maternity and newborn care
  • Mental health services
  • Substance use disorder services: These services include behavioral health treatment
  • Prescription drug coverage
  • Rehabilitative and habilitative services and devices: Rehabilitation includes services such as relearning to walk after a stroke and habilitation involves learning, keeping, or improving skills such as speaking without an impediment
  • Laboratory tests and services
  • Preventive and wellness services as well as the management of chronic diseases
  • Pediatric services (including both oral care and vision care)

Health plans are allowed to impose cost sharing obligations on plan members for most essential benefits, but those that qualify under a category of preventative health services will be made available at no charge to plan members.

The ACA gives states authority to specify details surrounding the essential benefits. The states must each choose a benchmark plan that will serve as a more detailed definition of benefits within each of the ten Essential Health Benefit categories.

Will Essential Health Benefit Requirements Affect My Coverage?

Health plans have a good idea regarding the types of coverage that the ACA considers to be essential, but significant details remain to be worked out. These definitions will impact many people, since an estimated 68 million consumers are expected to obtain a health plan covered by essential health benefit rules.

The insurance industry has warned that the essential health benefit requirement will add to the cost of providing individual and small employer health coverage. For example, currently over sixty percent of individual market plan members do not have coverage for maternity services and nearly twenty percent have no mental health coverage. Starting in 2014 plans would have to include those benefits in order to make them available for sale.

How HealthPocket Can Help

The essential benefit requirement is one of the ACA features that will create market improvements with the offsetting challenge of containing cost of the new requirements. Having standard coverage categories may make it easier for consumers to compare choices among the available plans within a specific state.

The delicate balance among benefits, cost and quality is HealthPocket's primary focus. The changes make it crucial for consumers to be aware of a plan’s benefit structure and costs as well as its ability to provide the highest level of quality possible. Each consumer’s health situation and needs will greatly influence which plan choice makes the most sense for them.



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