U.S. Department of Health and Humana Services (HHS) issued proposed rules addressing essential health benefits (EHB) and the determination of actuarial value (AV) in order to clarify key provisions of the Affordable Care Act.
The rules issued by HHS will cover the following:
The Affordable Care Act established core benefits that would be a part of all plans sold by insurance carriers and by the exchanges.
The proposed Essential Benefits Rule establishes that benefits be provided within the following 10 categories:
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance abuse services, including behavioral health treatment
- Prescription drugs
- Rehabilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
For plans to meet the EHB requirement, the benefits must be the equivalent to the benefits offered by a “typical employer plan”. Each state will establish a benchmark plan and each plan that offers EHB must offer benefits that are equal to the plan selected as the benchmark plan. If a state’s benchmark plan does not include all of the EHB categories HHS or the state can augment the coverage within the necessary category.
Actuarial Value (AV) is defined as the percentage of total average costs for covered benefits that a plan will cover. If a plan has an AV of 80% a consumer would be responsible for 20% of the costs of covered benefits.
The level of AVs will be required by each non-grandfathered plan, which began in 2014. The three levels have been assigned metallic descriptions, Gold, Silver and Bronze. Gold plans will have an actuarial value of 80%, silver plans will have an actuarial value of 70% and bronze plans will provide an actuarial value of 60%. The goal of establishing plans with the metal value descriptions is to make it easy for consumers to plans with similar benefits.
STATESIDE CAN HELP!
Stateside Insurance Services, since 2003, has focused on providing comprehensive health insurance information, responsive customer service and expert industry knowledge for Texas consumers. Stateside has annually been recognized by health insurance carriers and the Health Insurance Marketplace as a Top Producer in Texas.
Whether the health insurance policy is for an individual, family, small business or supplemental Medicare coverage, Stateside dedicates the time, and our deep industry expertise, to ensure our clients have identified the best health insurance plan for their specific needs.
Stateside is available to answer any general questions regarding your coverage options, can provide a subsidy determination, and even assist in creating and submitting online applications for ACA compliant plans during an Open Enrollment or throughout Special Enrollment periods.
By using the Telephone Appointment System, clients can take advantage of scheduling a health insurance discussion when convenient for their schedule. During Open Enrollment phone appointment availability is expanded to include extended hours and weekends.