The ACA defines EHBs by identifying ten categories of benefits that must be included in all health plans. These categories are:
- Ambulatory patient services
- Emergency services
- 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 oral and vision care
The new rules define expenses that must be covered within these ten categories. In The Department of Health and Human Services (HHS) has explained that each state should choose from a range of existing and popular (as measured by enrollment) health insurance plans to serve as an EHB benchmark plan.
Impact in California
Depending on the benchmark chosen by California, it is possible that more legislation will be necessary. The ACA provides that, beginning in 2014, to the extent that a state mandates coverage beyond EHB, the state must defray the cost of that additional coverage. California law currently contains fifty-three separate mandates to either offer coverage for, or cover treatment for specified conditions. Depending on what benchmark is chosen, California may have to choose between defraying the cost of some mandates and repealing them for future compliance.
- This rule does not apply to grandfathered plans.
- The limits do not apply to individual health insurance policies.
- The caps will be adjusted for inflation based on health insurance premiums.
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