The U.S. Department of Health and Human Services (HHS) issued a list of frequently asked questions (FAQ) in order to clarify the rules pertaining to the essential health benefits. The requirements for essential health benefits were included in the Patient Protection and Affordable Care Act (ACA) to promote consistency across plans, provide consumers protection by ensuring that plans cover a core package of benefits that are equal in scope to those offered by a typical employer plan, and limit the consumer’s out of pocket expenses. The essential benefits have been mandated since the beginning of January 2014.
The package of benefits as directed by the Secretary of Health and Human Services must include the following benefits at a minimum:
- Ambulatory patient services – healthcare services that are received without the patient being admitted to a hospital, such as a physician’s office or a surgical center.
- Emergency services – healthcare services that are received in a medical situation that poses the potential to result in death or a serious disability.
- Hospitalization – healthcare to be received once the patient is admitted to a hospital to include room, board, physician care, nursing care, laboratory tests, x-rays and imaging services, and drugs.
- Maternity and newborn care – healthcare services to be provided to women during the pregnancy, delivery, and recovery and to the newborn child.
- Mental health and substance abuse treatment – healthcare services to evaluate, diagnose and treat mental health disorders and substance abuse conditions.
- Prescription drugs –drugs prescribed by a physician to treat acute illnesses or ongoing conditions such as high cholesterol or high blood pressure.
- Rehabilitative and habilitative services and devices – services and devices provided to individuals with injuries, disabilities, or conditions in order to regain mental and physical skills.
- Laboratory Services – testing services to evaluate a patient’s blood, tissues or organs to provide information to a physician to aid in the diagnosis or treatment of a medical condition.
- Preventative and wellness services and chronic disease management – physicals, screening and immunizations conducted to promote preventative care and wellness. Chronic disease management is a healthcare service put in place to manage a chronic condition such as asthma or diabetes.
- Pediatric services – All of the previous nine listed preventative care benefits, in addition to dental and vision, targeting children only.
According to ACA, beginning January 2014 non-grandfathered plans (plans issued after March 23, 2010) must provide benefits equal to a benchmark plan that is selected by the state.
Benchmark plans must be one of the following:
- A current small group plan that is one of the three largest in the state.
- One of the three largest health plans offered to state employees.
- A health plan that is equal to one of the three largest federal employee health plans.
- The largest health maintenance organization (HMO) plan offered in the state’s commercial market.
Essential benefit plans will be available to consumers who secure coverage with plans inside the health insurance exchange and those plans marketed outside the health insurance exchange. The plans including essential health benefits will be available to both small group and individual plans.
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.