Starting on January 1, 2014, some health plans will need to include a certain set of benefits. These are called essential health benefits. The information below can help you learn what health care services are considered essential, which plans have to offer them and how your clients may be affected by them.
What are essential health benefits?
Essential health benefits are a set of 10 health care categories that plans for individuals and small businesses must cover. If members go to a doctor or hospital in network, they pay what they would pay for in-network care. If they go to a doctor or hospital outside the network, they may have to pay the out-of-network cost, unless it is an emergency. If the plan does not cover care out of network, these services may not be covered out of the network. These benefits apply to plans for individuals and small businesses both inside and outside the exchanges.
What are the 10 essential health benefits categories?
Are grandfathered plans affected by essential health benefits?
A grandfathered health plan is a plan that was in effect on or before March 23, 2010, and certain changes have not been made to it since then. Grandfathered plans do not have to include all essential health benefits.
Why is there a need for essential health benefits?
With essential health benefits, people who buy health insurance are assured they’ll have coverage of a full range of services.
Do limits apply to essential health benefits?
All plans or policies that began on or after September 23, 2010,will no longer limit how much they’ll pay out for essential health benefits in network. This applies to all plans and policies, except grandfathered individual health insurance plans.
Do essential health benefits have to be included in all plans on January 1, 2014?
No. The essential health benefits must be included in plans for individuals and small businesses on the first day of the plan year on or after January 1, 2014. The requirement does not apply to grandfathered plans or plans for large businesses. If an essential health benefit is covered as part of a plan, there cannot be dollar limits on the benefit.
It is important for you to know about essential health benefits so you can help your clients choose the right plan with the right benefits at the right cost. For more information on essential health benefits, check out these frequently asked questions or visit our health care reform website.