CSG Webinar: Essential Health Benefits: An Overview for State Legislators: February 28, 2012

The federal Affordable Care Act requires that individual and small group insurance sold in states after Jan. 1, 2014, both inside and outside the health insurance exchange, include a minimum package of essential health benefits (EHB). The Department of Health and Human Services estimates these plans will cover 30 million people, some of whom may currently be covered by plans with fewer benefits.

Sherry Glied, assistant secretary for Planning and Evaluation, U.S. Department of Health and Human Services, spoke on the CSG webinar Feb. 28 on the recent federal decision to allow state policymakers to set “essential health benefits.”

The federal Affordable Care Act requires that individual and small group insurance sold in states after Jan. 1, 2014, both inside and outside the health insurance exchange, include a minimum package of essential health benefits (EHB). The Department of Health and Human Services estimates these plans will cover 30 million people, some of whom may currently be covered by plans with fewer benefits.

In December, U.S. Department of Health and Human Services Secretary Kathleen Sebelius announced that rather than establish one federally designated set of essential health benefits, her department will give states the flexibility to select a benchmark plan from among designated existing plans in the state. Federal law requires a minimum package of benefits in following 10 specific coverage areas:

  • 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 ACA distinguishes between a plan’s covered services and the plan’s cost-sharing features, such as deductibles, copayments, and coinsurance. DHHS has also recently released information about cost-sharing. The cost-sharing features will determine the level of actuarial value of the plan, expressed as a “metal level” as specified in the ACA: bronze at 60 percent actuarial value, silver at 70 percent actuarial value, gold at 80 percent actuarial value, and platinum at 90 percent actuarial value.

For More Information:

  • December 2011 DHHS Bulletin on essential health benefits, click here
  • February 2012 Frequently Asked Questions on essential health benefits, click here.
  • February 2012 DHHS Bulletin on cost-sharing, click here

  Download the slides in PDF: Essential Health Benefits: An Overview for State Legislators

Essential Health Benefits: An Overview for State Legislators