Essential Health Benefits (EHB)
All major medical* plans will include coverage for Essential Health Benefits (EHB). This includes the following categories which are not subject to annual dollar limitations:
- 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 dental and vision care
Individual major medical plans and fully-insured small business plans will offer these benefits. The degree to which all of these benefits are covered, however, may vary by plan and by state. If you currently have an Assurant Health major medical plan, there’s a good chance that your plan may already cover a lot of these benefits.
Cost-sharing and coverage for out-of-pocket expenses
In 2014, all individual major medical plans will correspond to a metallic level (also known as a metallic plan) or a catastrophic plan. Metallic plans will have different cost-sharing attributes, also known as the actuarial value. Each metallic plan level will have to cover a certain amount of out-of-pocket expenses – which includes the deductible, coinsurance and any copays on the plan, but does not include the premium.
For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs for the in-network essential health benefits, up to your out-of-pocket maximum.
Percentage of out-of-pocket expenses covered by each plan type (actuarial value):
- Bronze – 60%
- Silver – 70%
- Gold – 80%
- Platinum – 90%
How each of these plans cover the set amount of out-of-pocket expenses may vary. For example, there could be two bronze plans, but each one may have a different combination of deductible, coinsurance and copays that will still meet the 60 percent actuarial value of that plan type.
What this means to you
These changes ensure that all consumers will have access to comprehensive health insurance. However, it is important to note that expanded coverage is a factor that will impact premium costs in 2014, along with all of the other changes that are going into effect.
Learn more about impacts to premium costs in 2014
*Applies to individual and small business fully-insured plans. Not all requirements apply to small business self–funded plans.
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