The Obama administration issued a final rule outlining the 10 broad categories of essential health benefits that most health insurance plans must offer in 2014 under the Affordable Care Act (ACA). Under the ACA, health plans in state exchanges must provide coverage for 10 categories of benefits, such as maternity care, prescription drugs and preventive care. Most of the rules include benefits that commonly are covered by plans, however, some of the changes expand coverage to include rehabilitative care, pediatric dental care and pediatric vision care. The rule also expanded coverage and federal parity protections for mental health and substance use disorder services.
The final rule prohibits insurers from discriminating based on an individual’s age, expected length of life, present or predicted disability, degree of medical dependency, quality of life or other health conditions.
The rule also sets four levels of coverage that new health policies offered on health insurance exchanges must offer. Consumers choosing bronze plans, which are the least generous policy, will pay an average of 40% of the costs of covered benefits, while insurers will pay the remainder. Those choosing platinum plans, the most generous policy, will pay 10% of the costs, and the insurer will pick up the rest.
The administration did not set a national standard and allowed states to set specific requirements for the minimum benefits to be covered in each essential health benefit category. Under the rule, each state could select a benchmark plan reflecting coverage typically offered by the largest plan by enrollment for employers. Health insurers have been waiting for the final rule before finalizing plans and pricing them. State insurance regulators must also approve the plans before they can be marketed.
