The ACA defines standards for both the types of benefits to be covered and the cost-sharing to be applied under the essential health benefits package. In addition, it sets actuarial value standards for plans, based on what is covered under the essential benefits package.
Plans will be offered on states’ mandated affordable state health insurance exchanges (Exchanges) which must include the EHB package – except for a few exceptions primarily involving grandfathered health plans – which will be deemed Qualified Health Plans (QHPs). Plans will be required to cover the full scope of benefits defined in the essential benefits package, but the level of cost-sharing an individual will face for a covered item or service will depend on the actuarial value of the policy the individual chooses to purchase. The essential health benefits are intended be similar to the typical employer-sponsored plan which exist today, with the addition of a few categories of coverage such as habilitative services.
Plans that are required to offer the essential health benefits package will also be required to limit the cost-sharing they charge. Specifically, plans providing the package will be prohibited from imposing an annual cost-sharing limit that exceeds the limits that apply to high deductible plans linked to health savings accounts. Additionally, small group plans must limit deductibles to $2,000 for individual coverage and $4,000 for family coverage. As with other health plans under the ACA, deductibles must not apply to evidence-based preventive health services, including those that have an A or B rating in the current recommendations of the United States Preventive Services Task Force. Annual and lifetime dollar limits have also been eliminated for most plans; however, states may still limit the number of annual visits for services.
By varying cost-sharing amounts within the allowable limits, each plan offered inside or outside of the exchanges will be required to provide a level of coverage that represents a specific fraction of the actuarial value of the full essential health benefits package. Plans will cover 60% (Bronze), 70% (Silver), 80% (Gold), or 90% (Platinum) of the full actuarial value of the essential health benefits for a standard population.
Initially, Exchange plans will only be available to small employers and to individuals who do not have an affordable offer of employer coverage and are not eligible for Medicare or Medicaid. Larger employers and others not eligible for Exchange plans will continue to purchase coverage outside of the Exchanges. The ACA requires that individual and small group plans offered outside the Exchanges include the essential health benefits package for any plans that begin after January 1, 2014. Additionally, beginning January 1, 2014, all new group health plans must limit the cost-sharing and deductibles to the limits specified for the essential health benefits package (but, as previously states, large group plans are not required to cover the EHBs).
The ACA authorizes states to offer a basic health plan instead of Exchange coverage to certain moderate-income individuals. These basic health plans must also cover the essential health benefits.
Under the ACA, many health plans will be required to offer the essential health benefits package. This requirement will ensure that enrollees have access to a more full range of services, including rehabilitative benefits.