The Department of Health and Human Services has issued its final rule on what kinds of coverage must be offered by almost all health plans starting in 2014.
The rule outlines the parameters for the so-called essential health benefits that must be included in health plans offered through the health exchanges, and in the individual and small group markets, and also sets out guidelines for an expansion of mental health and substance use disorders.
As outlined in previous proposals and bulletins from the Administration, the rule requires plans to cover services in 10 categories: 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; and pediatric services, including oral and vision care.
The final rule also spells out that health insurers must cover mental health and substance abuse services starting in 2014.
At that time, some 3.9 million Americans who currently have individual policies, and 1.2 million who are in small group plans will be covered for those benefits for the first time, according to the HHS.
The essential health benefit rule also broadens the parity requirement for mental health coverage, first established under the Mental Health Parity and Addiction Equity Act of 2008.
Health plans covered by the rule will also be categorized according to the value of the benefits they provide. The lowest-value plan will be bronze, in which patients will be responsible for about 40% of the costs of covered benefits. For the silver plans, policyholders will pay 30% of the costs; for a gold plan, 20%, and for a platinum plan, 10%.
As expected, the rule gives states a fair amount of flexibility in meeting the requirements for essential health benefits. But they must select a "benchmark" plan and offer benefits that are equivalent – either by matching benefits or providing the actuarial equivalent – to that benchmark.
The benchmark plan is required to include the services and benefits in the 10 categories. If the benchmark plan is missing any of those services, the final rule gives guidance on how the state or health plan can add the benefits.
Benchmark plans selected now will be used for coverage in 2014 and 2015.
Under the Affordable Care Act, the rule applies to all "non-grandfathered" health insurance plans offered through state health insurance exchanges, and also policies in the individual and small group market that are sold outside the exchanges.
Grandfathered plans are primarily those that were already in place when the ACA was signed into law on March 23, 2010.
HHS said that it received almost 6,000 comments on the various proposals it floated on the essential health benefits package since December 2011.
The final rule issued on Feb. 20 goes into effect on March 20.
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