Final Rules About What Health Plans Must Cover

Department of Health and Human ServicesThis is exactly what many health insurance companies, and many families, have been waiting to hear. The Obama administration has issued the final rules that define the Essential Health Benefits that must be covered in all health plans, starting in 2014. Here is a quick look at what will be included.

The Department of Health and Human Services has announced a final rule that defines what health insurance plans must cover. The rule applies to both individual plans and the small group markets. The purpose is to give consumers a consistent way to compare one health insurance plan with another. At the same time, states and health insurers are given some flexibility about what to cover.

It includes coverage for a core package of benefits that are called Essential Health Benefits. Health insurance companies who are both inside and outside the health insurance exchanges must cover these benefits. The 10 Essential Health Benefits are:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and rehabilitative services and devices
8. Laboratory services
9. Preventative and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

The Department of Health and Human Services notes that in the past, about 20% of individuals who purchased health insurance did not have access to mental health services. Around one third had absolutely no coverage for substance use disorder services. The rules are designed to fix that gap in coverage. Coverage for mental health services, substance use disorder services, will expand in the following ways:

* Mental health and substance use disorder benefits will be included as Essential Health Benefits.
* Federal parity protections to mental health and substance use disorder benefits will be applies to individual health plans and small group market plans
* Providing more Americans with access to quality health care that includes coverage for mental health and substance use disorders.

Starting in 2014, plans that cover Essential Health Benefits must cover a certain percentage of costs. Bronze Plans will cover 60% of costs. Silver Plans will cover 70% of costs. Gold plans will cover 80% of costs. Platinum Plans will cover 90% of costs. Together, the Essential Health Benefits, and the “metals” will make it easier for consumers to compare one health plan with another.

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