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Essential Health Benefits

Essential Health Benefits. Mim Dixon USET Training May 22, 2012. Affordable Care Act (ACA). Requires all new plans to have EHB QHPs and plans outside Exchanges Exempt from EHB requirement: Self-insured group health plans Large market health plans Grandfathered group market plans

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Essential Health Benefits

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  1. Essential Health Benefits Mim Dixon USET Training May 22, 2012

  2. Affordable Care Act (ACA) • Requires all new plans to have EHB • QHPs and plans outside Exchanges • Exempt from EHB requirement: • Self-insured group health plans • Large market health plans • Grandfathered group market plans • 10 categories of EHB in ACA • Secretary of HHS decides what services are included in each category

  3. Essential Health Benefits (EHB) • Ambulatory patient services • Emergency services • Hospitalization • Maternity and newborn care • Behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services • Laboratory services • Preventive and wellness services, chronic disease management • Pediatric, including oral and vision

  4. Why is EHB important for I/T/U? These are the covered services that you can be paid to deliver to people enrolled in health insurance plans.

  5. Benchmark Plans for EHB for Exchanges • HHS Secretary defers to States • States must choose benchmark from 3 largest in state in any of these categories: • Small group plan with largest enrollment • State employee benefit plan • Federal Employee Health Benefit Plan (FEHBP) • Commercial non-Medicaid HMO

  6. Default Benchmark Plan • Largest small group market product in the State’s small group market. • Federally-operated Exchanges will use default.

  7. Limitations on Benefits • Benchmark plans may limit number of visits or amount of service. • Exchange may substitute benefit categories, keeping actuarial value. • Must comply with Mental Health Parity and Addiction Equity Act (MHPAEA) • Pediatric oral and vision services may be offered by separate plans. • Orthodontics excluded, except medically necessary

  8. Limit on Limits • Plans may have limits on scope and duration of services. • Plans may not have annual or lifetime dollar limits on EHB. • Preventive services (under 2713 of PHS Act) must be part of EHB.

  9. Medicaid Expansion • State may use Exchange benchmark plan for EHB for • Medicaid Expansion population • Traditional Medicaid under Section 1937 • Basic Health Plan

  10. Tribal Consultation on EHB • Seek to have no limits number of visits, especially behavioral health. • Keep Medicaid plan EHB more generous than Exchange plans. • QHPs should include pediatric oral and vision services to make enrollment/sponsorship easier.

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