What Everyone Can Expect from ACA Essential Benefits

The Affordable Care Act’s Essential Health Benefits (EHB) provision created ten general categories of benefits outlined below. The requirements apply to all fully insured health plans offered in the individual and small group insured markets both inside and outside of the Exchanges. EHB requirements do not apply to ASO plans, fully insured large group plans or any grandfathered plans. All plans (even those that are not required to offer EHB) that include Essential Health benefits must remove any annual or lifetime dollar limits. The pricing impact of EHB will vary in each state depending on that states benchmark plan and the state specific EHB definition. EHB will become effective in the fully insured small group and individual markets upon renewal in 2014.

The following are the ten Essential Health Benefits:

Prescription Medications
This is currently an option with most plans but not mandatory. However, the new law will make all small group and individual plans cover at least one drug in each class and category of the United States Pharmacopeia. Prescription costs will count toward upfront expense caps.

Ambulatory Services
This is also called outpatient care, and it happens when a person goes in to be treated and leaves the same day. Most health plans currently offer this form of coverage, but the new law will ensure that network sizes for these offerings are sufficient.

Mental Health
Coverage will be limited to a specific number of sessions, and patients may be billed a small amount for each one.

Rehabilitative Services
People who suffer injuries or illnesses today may or may not have rehabilitative services on their policies. The new plans must cover these services and equipment items such as braces, canes, wheelchairs, walkers and other essential devices. Habilitative services will also be added, and these are rarely covered in existing plans. They help people cope with the slow effects of long-term illnesses such as multiple sclerosis.

With the new law, an insurer must provide coverage for hospital stays. However, patients may be responsible for 20 percent or more of the total bill if an out-of-pocket limit has not been reached. With average hospital stays often exceeding $2,000 per day, experts felt that this was an important inclusion.

Emergency Care
Under most existing plans, emergency care is covered. Many providers charge a fee for out-of-network emergency services, or they may require pre-authorization. With the new law, these two requirements will no longer exist.

Maternity And Newborn Care
The new law will classify prenatal care as a preventative service, so there will be no extra cost. It will also require all insurers to cover childbirth and infant care.

Pediatric Care
Although few current health plans cover dental, orthodontic and vision care, the new law will set provisions for those areas for kids under the age of 19. Each one will be able to receive medically necessary orthodontic care, fillings, x-rays and two teeth cleaning sessions per year.

Wellness And Preventative Services
The purpose of this benefit is to keep the number of needs-related doctor visits down. Experts say that if people make healthier choices for their lifestyles, the need for serious medical care will lessen. Every person will be allowed one free wellness visit per year, and 50 other preventative health services are also available.

Laboratory Services
Preventative screening tests will be required as part of the new law, but patients may still be billed a small amount for diagnostic tests. Costs may range from $20 to up to 30 percent of an MRI.

Other changes to expect in 2014

Out-of-Pocket Maximum limits – The new accumulation rules for out-of-pocket maximum (OOPM) which apply for all funding types and employer sizes. The OOPM will be $6,350 (for self only coverage) and $12,700 (for other than self-coverage) in 2014, with future increases indexed for inflation. All cost sharing for EHB must accumulate to the OOPM. For plans that have in and out-of-network benefits, only the in-network benefits are subject to the OOPM.

Excessive waiting period limitations – In group markets of all sizes and funding, a maximum waiting period of 90 days will take effect on January 1, 2014 upon a group’s renewal.

Small group deductible limits – The deductible caps is for Small Groups plain in 2014 have been set at $2,000 for single coverage and $4,000 for family coverage. The deductible caps will be will be indexed for inflation.

Pre-existing condition – This exclusion must be removed for all members, not just those under age 19, and all fully insured plans must have guaranteed issue and renewability

Health insurance plans will certainly see several changes as the new law takes effect.

At Cleary, we know how important a comprehensivee benefits package can be to your continued success. Give us a call today at 617-723-0700 and we will work with you to create a plan that meets your business objectives, takes into account state and federal laws, and capitalizes on incentives and innovative solutions now being offered.