Essential Health Benefits and the ACA 2014



Essential Health Benefits and the ACA - Will health plan coverage look different in 2014?

Essential Health Benefits (EHB) are health services that the department of Health and Human Services deems to be vital to quality health care. Health care reform dictates that these services are required – essential – benefits for health insurance companies to include in their plans.   Every health insurance company that participates in Health Care Exchanges must offer all of these benefits in their offered health plans. Importantly, not every benefit will be 100% covered by the premium, but these services must be included in every plan.  

According to the Affordable Care Act (ACA), Essential Health Benefits include:
  • office visits
  • emergency services
  • hospital stays
  • maternity and newborn care
  • mental health disorder services
  • substance abuse disorder services
  • lab services
  • preventive and wellness visits
  • prescription drugs
  • dental care for children and
  • rehabilitative and habilitative services and devices.
With the exception of dental and vision care for children, most health plans already cover these services. Additionally, pediatric dental must be offered, but purchasing it is optional.  

A big difference between health plans now and health plans after January 1, 2014 will be how much care is covered in any given year. Annual dollar limits on Essential Health Benefits will not be allowed under the ACA. This means your coverage for Essential Health Benefits will not be limited based on costs of care. How the health insurance company and individual share those costs in rates, deductible and co-insurance will be a distinction between plans.  

Will you experience changes in your Essential Health Benefits coverage with Health Care Reform?   It depends on the plan you have today.   Most likely, if your plan does not currently meet these EHB requirements, your health insurance company must present you with a different plan that does cover these benefits; however, you may recall President Obama’s promise of “If you like your health plan today, you can keep your health plan.” Here is where it gets a little complicated.  

Employers and individuals enrolled in a private health plan on or before March 23, 2010 without major changes, may stay with that health plan indefinitely.   Aside from these plans, termed “Grandfathered plans”, the EHB will guide the content and coverage of all health plans.   Additional information on grandfathered plans is available, but the date of enrollment and limits in coverage changes are two fundamental identifiers in being able to keep that plan.  

Consistent coverage and appropriate use of the health care system are foundations to an affordable and effective health care system. Essential health benefits make sure that all members have access to vital care they need.   Do you have more questions about health care reform? Visit our health care reform site and let us know!