Navigating Essential Health Benefits

• Require all plans offered in the individual and small group markets to cover ten categories of essential health benefits: ambulatory care, emergency care, hospitalization, maternity and newborn care, mental health and substance use care, prescription drugs, rehabilitative and habilitative services, laboratory services, preventive care, chronic disease management, and pediatric dental and vision care.
• Require all plans offered in the individual and small group markets to cover ten categories of essential health benefits including maternity care and preventive care, such as contraception and cancer screenings.
• Expand Medicaid eligibility to all non-elderly adults with incomes up to 138% FPL based on modified adjusted gross income at state option. As under current law undocumented immigrants are not eligible for Medicaid. Provide newly eligible adults with a benefit package that meets the essential health benefits.

Source: kff.org

• Retain private market rules, including requirement to guarantee issue coverage, prohibition on pre-existing condition exclusions, requirement to extend dependent coverage to age 26. Modify age rating limit to permit variation of 5:1, unless states adopt different ratios, effective 2018. Retain essential health benefits requirement, with state option to waive. Retain prohibition on health status rating with state option to waive for individual market applicants who have not maintained continuous coverage.
• Premium tax credits can be used to purchase qualified health plans (i.e., covering essential health benefits) sold outside of the exchange, but are not advance-payable for such plans. Premium tax credits cannot be used to purchase short term policies or grandfathered or grandmothered individual health insurance policies sold outside of the exchange.
• Prohibition on lifetime and annual dollar limits is not changed; however, the prohibition applies to limits on essential health benefits, which can be changed under state waiver authorityRepeal the essential health benefits requirement for those receiving alternative benefit packages, including the expansion group, as of December 31, 2019.
• Repeal the essential health benefits requirement for those receiving alternative benefit packages, including the expansion group, as of December 31, 2019.

Source: kff.org