Health Care Reform Update:
Essential Health Benefits

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Health Care Reform Update:
Essential Health Benefits

The Affordable Care Act (ACA) requires that starting January 1, 2014, every health insurance plan you sell in the individual and small group markets must offer a minimum level of coverage for what the ACA calls “Essential Health Benefits” (EHBs). This is a key factor for achieving the ACA’s goal that all Americans have access to quality, affordable health care. As such, coverage for EHBs will be required for all individual and small group plans sold on and off the Exchange. They must include the following 10 broad categories of care:

  • Ambulatory patient 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

Benchmark Plan for EHBs

Under the ACA, each state must choose one plan from among popular health insurance plans offered statewide to serve as a benchmark for EHBs. The benchmark plan will act as the model for how plans must define and include EHBs in their coverage ó in both the individual and small group markets. New York selected the benefits of the State's largest small group plan as its EHB benchmark. Some of the planís components include:

  • No cost-sharing for routine preventive services
  • Pediatric dental and vision coverage
  • Habilitative and rehabilitative services, including physical therapy, speech therapy and occupational therapy
  • Rich mental/behavioral health services
  • No annual or lifetime dollar limits on benefits

At EmblemHealth, we are in the process of ensuring that all of the individual plans we will be selling on and off the Exchange — as well as small group plans sold off the Exchange — will be compliant with state and federal standards for EHBs.

*The federal government defines habilitative services as health care services that help a person keep, learn or improve skills and functioning for daily living. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.


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