Benefit Design Essential Benefits Package
- Essential Benefits Package. Services must include:
- Ambulatory patient services;
- Emergency services;
- Hospitalization;
- Maternity and newborn care;
- Mental health and substance abuse disorder services “including behavioral health treatments”;
- 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.
- Must meet emergency coverage requirements (e.g., does not require prior authorization and charges the same cost-sharing for out-of-network emergency services as in-network).
- Scope Equal to “Typical Employer Plan.” The scope of these essential benefits will be equal to the scope of benefits provided under a “typical employer plan” – according to HHS. To inform the decision, DOL will conduct a survey of employer plans, including multiemployer plans. Certification will be conducted by the CMS Actuary.
- Definition of Benefits. In defining the essential benefits, requires HHS to:
- Make sure all benefits are given equal importance and emphasis.
- Not make coverage decisions, rate determinations or incentive programs or structure benefits that discriminate against anyone based on age, disability or expected lifespan.
- Take into account the diverse health care needs of the population.
- Make sure that essential benefits are not involuntarily denied to anyone on the basis of age or expected lifespan or disability, medical dependency or quality of life.
- Periodically review and update essential health benefits.
- Cost-Sharing
- Limits cost-sharing (deductible, coinsurance, copayments, etc.) to Health Savings Account (HSA) cost-sharing limits in 2014 and then indexed annually to per capita premium increases measured after 2013.
- Small group employer plans. Limits deductibles to $2,000/single, $4000/family.
- Indexing
- These limits can be raised by the maximum amount of reimbursement which is reasonably available to a participant under a flexible spending arrangement (FSA).
- Indexes the individual limits annually to per capita premium increases measured after 2013. For any other plans, the limits will be indexed to double the individual increase. (PPACA § 1302)
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