Essential Health Benefits
The U.S. Department of Health and Human Services (HHS) released the final regulations about essential health benefits (EHB) on February 20, 2013. The guidance defines the benefits that must be included with all fully insured plans sold inside and outside of the public exchanges in 2014. This will impact all individual health plans and most small group health plans. Grandfathered plans and self-insured plans are exempt from the EHB requirements; however, self-insured plans that cover any EHB must provide coverage without any annual or lifetime dollar limits.
Many people had questioned whether the final regulations would include the requirement to cover benefits such as birth control, maternity, substance abuse treatment, habilitative services and pediatric dental/vision care. After taking into account more than 11,000 public comments the final regulations confirm these benefits and others must be included with all fully insured plans starting next year. We now know that all fully insured plans must include coverage for 10 categories of EHB without any annual and lifetime dollar limits for the following benefits:
- Ambulatory Patient Services
- Emergency Services
- Hospitalizations
- 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
- Pediatric Services, Including Dental and Vision Care
The state of Illinois has released details for their EHB benchmark plan. All fully insured plans will have to provide EHB that meet or exceed the benchmark plan requirements, or that provide benefits of actuarial equivalence to the EHB defined in the benchmark plan. Links to the state of Illinois benchmark plan along with the final EHB regulations are provided below.
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