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Feds release final rule on essential health benefits

February 21, 2013
Area(s) of Interest: Health Care Reform 


The picture of what health insurance coverage will look like under federal health reform has gotten a little clearer.


On Wednesday, the U.S. Department of Health and Human Services released a final rule detailing "essential health benefits" (EHB) that plans must offer by 2014 under the Patient Protection and Affordable Care Act (ACA). While the news comes as a major step in ACA implementation, the final ruling itself held few surprises when compared to the proposed rule that had been issued in November of last year.


Both the proposed and final rule would require insurance plans to cover 10 broad categories, including ambulatory patient care, emergency and hospital services, prescription drugs and several others. The majority of these benefit categories are commonly covered by plans, however the final rule did expand coverage in the areas of rehabilitative care, pediatric dental and pediatric vision coverage. The rule also calls for a major expansion of mental health coverage.


The rule also clarified the required cost sharing structure that will be present under the so-called "metal tier" structure called for under the ACA. Four tiers of health plans – platinum, gold, silver and bronze – will be offered to consumers, with the percentage of coverage varying across the tiers. It further clarified that the out-of-pocket limits, $6,400 for an individual and $12,800 for a family in 2014, will apply to all group plans and not just individual and small group coverage.


Last week, Covered California, the state’s health benefit exchange, posted its finalized cost-sharing standards that said metal tier plans would offer 90 percent, 80 percent, 70 percent and 60 percent cost coverage across the respective metal tiers. However, questions about the affordability of these plans’ premiums remain.


As was expected, the feds did not set a national standard for the level of coverage that must be offered in each benefit category, instead opting to allow states to set their own "benchmarks" using model plans offered by employers. Last session, members of the California Legislature approved a bill that set the Kaiser Small Group HMO plan as the state’s EHB benchmark plan.


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