Essential Health Benefits

One of the goals of Obamacare is to achieve standardization of health benefits for health insurance plans. This is achieved through the establishment of an essential health benefits package. Without standardization, it was difficult to know exactly whether certain health benefits were part of the plan, and comparison of different plans was difficult. Many important health benefits that most people need at some point in their lives were not included in insurance health plans. Essential Health Benefits are a minimum set of benefits that all individual and small group plans (excluding grandfathered plans) must offer.

What benefits are included in Essential Health Benefits?

The list of essential health benefits includes:

  • ambulatory patient services, such as doctor’s visits and outpatient services
  • emergency services
  • hospitalization
  • maternity and newborn care
  • mental health and substance use 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

Presently, the law does not define specific services that must be covered; nor the amount, duration, or scope of services. These issues should be addressed in the future.

Cost-Sharing and Deductible Benefits Standards

They include:

  • In 2014, non-grandfathered group health plans will be prohibited from imposing a deductible greater than $2,000 for self only coverage, or $4,000 for coverage other than self only.
  • Out-of-pocket costs for most health plans will be capped at the health savings accounts (HSA) limit ($6,400 for individual and $12,800 for family) in 2014.
  • No copays for approved preventive services.
  • All exchange plans must have the pre-specified level of coverage defined by actuarial values: Bronze – 60%, Silver – 70%, Gold – 80%, and Platinum – 90%. The minimum allowable actuarial value is 60%. Actuarial value is the average amount of financial coverage than the plan offers to its policyholders. The minimum allowable actuarial value is the Bronze level (60%).

For the full list of benefits, see Obamacare Benefits and Protections.

Plans and their Essential Health Benefits (Starting Jan. 1, 2014)

For Individual and Small Group Plans:

  • New plans: both essential health benefits and cost sharing / deductible limits must be provided
  • Grandfathered plans: neither essential health benefits nor cost sharing / deductible limits should be provided

For Large Group Plans:

  • New plans: there are no requirements for essential health benefits; however, cost sharing / deductible limits must be provided
  • Grandfathered plans: neither essential health benefits nor cost sharing / deductible limits should be provided

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For help finding the best Medicare or Individual Health Plan for you, please contact Liberty Medicare or call us at 877-657-7477.

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