Taking the Easy Way Out this week!

Well, there is too much changing for me to go out on a limb and try to tell you what the ACA is going to do this week, so I decided to take the easy way out and just pass along some information about the Essential health benefits required by the act.  I have to credit my friends at Anthem/Wellpoint for this summary that they provided me.  This is still accurate as far as I know.  Good luck out there, and if you need assistance, make sure to go to our website www.llhins.com We are ready to offer assistance.

Essential health benefits (EHBs)           

Summary

On February 20, 2013, new rules was released by the Centers of Medicare & Medicaid Services (CMS), the Department of Health and Human Services (HHS) and Department of Labor ( DOL)

Effective for new and renewing plans on and after January 1, 2014, all non -grandfathered, fully insured small group and individual health plans must cover essential health benefits (EHBs).

Also effective for new and renewing plans on and after January 1, 2014, all health plans, regardless of group size or funding type, must apply all member cost share for in-network services and out-of-network emergency services to the in-network out-of- pocket (OOP) maximum, which cannot exceed $6,350/$12,700.

All copayments, coinsurance and deductible amounts for EHBs must apply to the out -of-pocket maximum. No annual or lifetime dollar limits are allowed on EHBs, but other types of limits can be put in place including,

·        visit limits (e.g., 20 visits per CY)

·        day limits (e.g., 30 days per lifetime)

·        occurrence limits (e.g., 1 wig per CY)

·        per episode or per service limits (e.g.,$1,500 per hearing aid) 

Definitions

Essential health benefits (or EHB) package: the covered benefits and related limits of a health plan offered by an issuer based on the EHB-benchmark plan; provides at least the  ten statutory categories of benefits, limits cost sharing for such coverage, subject to offering catastrophic                                                                  .

·        Base-benchmark plan: the plan selected by a state from (or through the default process) before adjustments are made to meet the benchmark standards. (Details can be found in the Code of Federal Regulations §156.110.)

·        EHB-benchmark plan: the standardized set of EHBs that must be included in all non-grandfathered, fully-insured small group and individual health plans beginning in 2014.

State selection: serves as a reference plan and reflects the services and related limits offered by a typical employer plan in that state; applies to at least 2014 and 2015 benefit years.

Default base-benchmark plan: states that did not make a benchmark plan selection defaulted to the plan with the most

Final rule: EHB package

EHB-benchmark must provide coverage of at least the following categories of benefits:

1.    Ambulatory patient services

2.    Emergency services

3.    Hospitalization

4.    Maternity and newborn care

5.    Mental health and substance use disorder services, including behavioral health treatment

6.    Prescription drugs

·        Must cover the greater of either one drug in every United States Pharmacopeia (USP) category and class, or the same number of prescription drugs in each category and class as the EHB -benchmark plan

·        Must have procedures in place that allow a member to request clinically appropriate drugs not covered by the health plan

·        Does not require coverage of all drugs in protected classes as defined in Medicare Part D

7.    Rehabilitative and habilitative services and devices

·        The final rule allows states with benchmark plans that do not include coverage for habilitative services to determine which services are included in that category.

·        States that decline to specify habilitative services are required to either provide parity by covering habilitative services benefits that are similar in scope, amount and duration to benefits covered for rehabilitative services, or is determined by the issuer and reported to HHS.

8.    Laboratory services

        9.    Preventive and wellness services and chronic disease management
     10.  Pediatric services, including oral and vision care

·        Pediatric services means services for individuals under the age of 19

·        Benchmark plans that do not provide coverage  for pediatric oral and vision services are required to cover these services from one of the following:

·        The Federal Employees Dental and Vision Insurance  Program (FEDVIP) with the largest enrollment (CHIP) 

Large group and self-funded (ASO) health plans do not need to offer all 10 categories of essential health benefits, or meet actuarial value requirements that non-grandfathered small group and individual policies have to meet. The rule is still important to large group and self-funded (ASO) plans because they are subject to many rules tied to EHBs such as:

·        The out-of-pocket maximum applies to EHBs
·        EHBs covered by a large group or self-funded (ASO) plan cannot have annual or lifetime dollar limits

 

Credit Anthem Blue Cross Blue Shield for content