The Affordable Care Act: Essential Health Benefits

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The Affordable Care Act can be hard to understand and our goal is to provide a valuable resource to help you navigate the ACA and understand how it will affect the future of healthcare.​

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​One of the key mandates of the ACA is Essential Health Benefits (EHB). The law states that all nongrandfathered plans in the Individual and Small employer markets both inside and outside of exchanges must cover EHB beginning January 1, 2014, for new business and at renewal for existing business.

Large Employer and Self-funded plans are not required to cover EHB. However, the EHB they do cover may not have any annual or lifetime dollar limits. All SelectHealth Small Employer and Individual plans are considered non-grandfathered. There are ten categories of EHBs:
  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance abuse
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Lab services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care
The law directs each state to establish a benchmark plan that will determine covered services to a greater level of detail within these categories. Utah selected the PEHP Basic plan as its benchmark. Idaho has defaulted to the Blue Cross of Idaho group plan as the EHB benchmark for medical care and the MetLife FEDVIP as the benchmark for pediatric dental and vision care.

While not required, Large Employer and Self-funded plans can use the state-selected benchmark plan or any other benchmark plan approved by CMS. Although the benchmark plans set a standard for benefits in each category, the specific benefits may vary between carriers and even plans. This is because insurers can substitute benefits within a category with other benefits that are substantially equal in actuarial value. Substitution between categories is not permitted.

You can also find information about the ACA on selecthealth.org/reform. This site includes details about the changes that have been implemented since the law was passed, including:
  • Reform
  • Timeline
  • Ongoing Information
  • Claims and appeals
  • Lifetime limits
  • Tax credits
  • Pre-existing conditions
  • Dependent care expansion
  • Preventive care