Essential Health Benefits: What You Need to Know

Posted by CFR Multimedia
CFR Multimedia
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on Wednesday, 04 April 2012
in Benefits Buzz

Part of health care reform is a provision that certain plans include "essential health benefits" (EHBs) starting in 2014. Here's what employers should know.

Beginning in 2014, health plans in the small group and individual market will be required to cover defined EHBs. The EHB package must include:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance abuse treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services

Each state will be required to establish an EHB benchmark package that small group and individual plans must match in terms of coverage.

The Department of Health and Human Services released FAQs with more guidance on how states may choose this benchmark plan. For instance, states will choose a benchmark plan in the third quarter of 2012, which will apply for 2014 and 2015. Access full FAQs here: http://cciio.cms.gov/resources/files/Files2/12162011/essential_health_benefits_bulletin.pdf

Large group health plans and self-insured group plans are not required to cover EHBs under the health care reform law, but still have an obligation. These plans may not impose annual or lifetime dollar limits on benefits defined as an essential health benefit. Therefore, it is vital that large group and self-insured plans identify essential health benefits within their plan to ensure compliance.

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