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The Essential Benefits Package Must Balance Affordability And Coverage For Small Businesses, Individuals, And Families

posted by Federal Affairs

on January 11, 2013

Background

The Affordable Care Act (ACA) requires insurers to provide coverage for the “essential health benefits” (EHB) package—effective January 1, 2014. These requirements apply to qualified health plans in the exchange as well as health insurance plans offered in the small group and individual markets outside the Exchange. EHB requirements do not apply to health insurance coverage provided in the large group market (either fully-insured or self-funded) nor do they apply to “grandfathered” health plans.

Under the ACA, the EHB provisions require insurers to:

  • Provide coverage for broad categories of services—as specified under the statute
  • Limit annual cost-sharing to specified amounts (e.g. annual OOP limits) ; and limit deductibles for plans in the small group market; and
  • Meet minimum standards for actuarial value.

The ACA also requires that the scope of the EHB package must be equal to the scope of benefits covered under a typical employer plan, as determined by HHS.

On November 20, 2012, the U.S. Department of Health and Human Services (HHS) released a proposed rule that details standards for health insurers related to coverage of essential health benefits and actuarial value. In addition, the rule proposes a timeline for qualified health plans to be accredited in the federally-facilitated exchange and provides an application process for the recognition of additional accrediting entities for purposes of certifying qualified health plans.