Essential Health Benefits

A Benefit Floor for All Health Plans

The Affordable Care Act (ACA) includes the following categories meant to set a benefit floor for all health insurance plans from 2014 going forward:

  • ambulatory patient services
  • emergency services
  • hospitalization
  • maternity and newborn care
  • mental health and substance abuse disorder services, including behavioral health treatment
  • prescription drugs
  • rehabilitative and habilitative services and devices
  • laboratory services
  • preventive and wellness services and chronic disease management
  • pediatric services, including oral and vision care

New Benefits

Most of the essential benefits commonly are covered by current plans, However, some changes represent an expansion of coverage to include rehabilitative care, pediatric dental care and pediatric vision care. Expanded coverage and federal parity protections for mental health and substance use disorder services, including behavioral health treatment, to both the individual and the small group market are also represent higher levels of coverage.

Benefit Plan Benchmark

States can define their own set of essential benefits by using an existing major health benefit plan in the state as a benchmark. California has chosen to use the Kaiser Permanente HMO 30 Plan - the largest small-group employee health benefit plan by enrollment in the state.

Affordability of Coverage

Insurers and some business groups had lobbied the federal government to scale back the scope of mandated coverage categories because of concerns that such coverage would make policies too costly. However, rather than scale back benefits, the feds included several ways to limit the costs to consumers, such as capping total out-of-pocket costs and limiting the deductible amount for plans offered in the small-group market to about $2,000 for an individual and $4,000 for a family.

Return to Index of Challenges the Exchange Must Overcome

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