Requirements Generally Apply to Plans Offered in Individual and Small Group Markets
Under the Affordable Care Act (ACA) and its corresponding regulations, non-grandfathered health plans offered in the individual and small group health insurance markets are generally required to cover a core package of items and services known as “essential health benefits.” (This requirement does not apply to self-insured plans or plans offered in the large group market.)
Essential health benefits must include items and services in the following ten benefit categories:
1. Ambulatory patient services;
2. Emergency services;
4. Maternity and newborn care;
5. Mental health and substance use disorder services, including behavioral health treatment;
6. Prescription drugs;
7. Rehabilitative and habilitative services and devices;
8. Laboratory services;
9. Preventive and wellness services and chronic disease management; and
10. Pediatric services, including oral and vision care.
The essential health benefits must be equal in scope to benefits offered by a “typical employer health plan.” A final rule issued by the U.S. Department of Health and Human Services defines essential health benefits based on state-specific essential health benefits benchmark plans, and provides that all plans subject to the essential health benefits requirements offer benefits substantially equal to the benefits offered by the benchmark plan. For more information on EHB-benchmark plans for each of the 50 states and D.C., click here.
Note: If allowed by a particular state and insurance company, a small business may be able to renew its current group plan through December 31, 2018, even though the coverage does not comply with the requirement to cover essential health benefits.
Click here for more information on essential health benefits.
Visit our ACA by Year & Company Size section for an overview of other ACA requirements.
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Please Note: The information and materials herein are provided for general information purposes only and are not intended to constitute legal or other advice or opinions on any specific matters and are not intended to replace the advice of a qualified attorney, plan provider or other professional advisor. This information has been taken from sources which we believe to be reliable, but there is no guarantee as to its accuracy. In accordance with IRS Circular 230, this communication is not intended or written to be used, and cannot be used as or considered a ‘covered opinion’ or other written tax advice and should not be relied upon for any purpose other than its intended purpose.
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