This month’s post covers Essential Health Benefits (EHB). The final rule confirms prior guidance defining EHB based on a state-specific benchmark plan and requiring all plans that cover EHB to offer benefits that are substantially equal to those offered by the benchmark plan.
ACA’s essential health benefits requirement applies to non-grandfathered plans offered in the individual and small group markets, both inside and outside of the Exchanges. Self-insured group health plans, health insurance coverage offered in the large group market and grandfathered plans are not required to cover essential health benefits.
ACA requires the EHB package to be equal in scope to the benefits covered by a typical employer plan. Additionally, the EHB package must include items and services within at least the following 10 general categories: Ambulatory patient services; Emergency services; Hospitalization; Maternity and newborn care; Mental health and substance use disorder benefits, including behavioral health treatment; 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.
Actuarial value (AV) is calculated as the percentage of total average costs for covered benefits that a plan will cover. Beginning in 2014, non-grandfathered health plans in the individual and small group markets must meet certain levels of AV (or “metal levels”): 60 percent for a bronze plan; 70 percent for a silver plan; 80 percent for a gold plan; and 90 percent for a platinum plan. In addition, issuers may offer catastrophic-only coverage with lower AV for eligible individuals. “Metal levels” are intended to allow consumers to compare plans with similar levels of coverage in order to help consumers make an informed decision about their health insurance coverage.
HHS has provided an AV calculator to help issuers determine health plan AVs based on a national, standard population. The final rule allows health plans some flexibility in meeting the metal levels if the actuarial value is within two percentage points of the standard. For example, a silver plan may have an AV between 68 percent and 72 percent.