What Marketplace Health Insurance Plans Cover

Do you know what is covered in your marketplace health insurance plan? Find out more about your health insurance plan and everything it covers in this article by HealthCare.Gov.

All plans offered in the Marketplace cover the same set of essential health benefits.

Every health plan must cover the following services:

  • Ambulatory patient services (outpatient care you get without being admitted to a hospital)
  • Emergency services
  • Hospitalization (like surgery and overnight stays)
  • Pregnancy, maternity, and newborn care (both before and after birth)
  • Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
  • Prescription drugs
  • Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits)

Additional benefits

Plans must also include the following benefits:

Essential health benefits are minimum requirements for all Marketplace plans. Specific services covered in each broad benefit category can vary based on your state’s requirements. Plans may offer additional benefits, including:

When comparing plans, you’ll see exactly what each plan offers.

See the original article Here.


Author (Date). What marketplace health insurance plans cover [Web blog post]. Retrieved from address https://www.healthcare.gov/coverage/what-marketplace-plans-cover/

Late Move To Dump ‘Essential’ Benefits Could Strand Chronically Ill

Are you worried about your health benefits will change with the passing of the AHCA? Take a look at this article by Jay Hancock from Kaiser Health News and find out how your 'essential' benefits could be cut with the passing of the AHCA.

A last-minute attempt by conservative Republicans to dump standards for health benefitsin plans sold to individuals would probably lower the average consumer’s upfront insurance costs, such as premiums and deductibles, said experts on both sides of the debate to repeal and replace the Affordable Care Act.

But, they add, it will likely also induce insurers to offer much skimpier plans, potentially excluding the gravely ill, and putting consumers at greater financial risk if they need care.

For example, a woman who had elected not to have maternity coverage could face financial ruin from an unintended pregnancy. A healthy young man who didn’t buy drug coverage could be bankrupted if diagnosed with cancer requiring expensive prescription medicine. Someone needing emergency treatment at a non-network hospital might not be covered.

What might be desirable for business would leave patients vulnerable.

“What you don’t want if you’re an insurer is only sick people buying whatever product you have,” said Christopher Koller, president of the Milbank Memorial Fund and a former Rhode Island insurance commissioner. “So the way to get healthy people is to offer cheaper products designed for the healthy people.”

Such a change could give carriers wide room to do that by eliminating or shrinking “essential health benefits” including hospitalization, prescription drugs, mental health treatment and lab services from plan requirements — especially if state regulators don’t step in to fill the void, analysts said.

As part of the push by House GOP leaders to gain more support for their plan, they amended the bill Thursday  to allow states to decide, starting next year, what if any benefits  insurers must provide on the individual market, rather than requiring health plans to include the law’s essential health benefits, according to House Ways and Means Chairman Kevin Brady (R-Texas).

The Affordable Care Act requires companies selling coverage to individuals and families through online marketplaces to offer 10 essential benefits, which also include maternity, wellness and preventive services — plus emergency room treatment at all hospitals. Small-group plans offered by many small employers also must carry such benefits.

Conservative House Republicans want to exclude the rule from any replacement, arguing it drives up cost and stifles consumer choice.

On Thursday, President Donald Trump agreed after meeting with members of the conservative Freedom Caucus to leave it out of the measure under consideration, said White House Press Secretary Sean Spicer. “Part of the reason that premiums have spiked out of control is because under Obamacare, there were these mandated services that had to be included,” Spicer told reporters.

Pushed by Trump, House Republican leaders agreed late Thursday to a Friday vote on the bill but were still trying to line up support. “Tomorrow we will show the American people that we will repeal and replace this broken law because it’s collapsing and it’s failing families,” said House Speaker Paul Ryan (R-Wis.). “And tomorrow we’re proceeding.” When asked if he had the votes, Ryan didn’t answer and walked briskly away from the press corps.

But axing essential benefits could bring back the pre-ACA days when insurers avoided expensive patients by excluding services they needed, said Gary Claxton, a vice president and insurance expert at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

“They’re not going to offer benefits that attract people with chronic illness if they can help it,” said Claxton, whose collection of old insurance policies shows what the market looked like before.

One Aetna plan didn’t cover most mental health or addiction services — important to moderate Republicans as well as Democrats concerned about fighting the opioid crisis. Another Aetna plan didn’t cover any mental health treatment. A HealthNet plan didn’t cover outpatient rehabilitative services.

Before the ACA most individual plans didn’t include maternity coverage, either.

The House replacement bill could make individual coverage for the chronically ill even more scarce than a few years ago because it retains an ACA rule that forces plans to accept members with preexisting illness, analysts said.

Before President Barack Obama’s health overhaul, insurers could reject sick applicants or charge them higher premiums.

Lacking that ability under a Republican law but newly able to shrink benefits, insurers might be more tempted than ever to avoid covering expensive conditions. That way the sickest consumers wouldn’t even bother to apply.

“You could see even worse holes in the insurance package” than before the ACA, said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University. “If we’re going into a world where a carrier is going to have to accept all comers and they can’t charge them based on their health status, the benefit design becomes a much bigger deal” in how insurers keep the sick out of their plans, she said.

Michael Cannon, an analyst at the libertarian Cato Institute and a longtime Obamacare opponent, also believes dumping essential benefits while forcing insurers to accept all applicants at one “community” price would weaken coverage for chronically ill people.

“Getting rid of the essential health benefits in a community-rated market would cause coverage for the sick to get even worse than it is under current law,” he said. Republicans “are shooting themselves in the foot if they the offer this proposal.”

Cannon favors full repeal of the ACA, allowing insurers to charge higher premiums for more expensive patients and helping consumers pay for plans with tax-favored health savings accounts.

In an absence of federal requirements for benefits, existing state standards would become more important. Some states might move to upgrade required benefits in line with the ACA rules but others probably won’t, according to analysts.

“You’re going to have a lot of insurers in states trying to understand what existing laws they have in place,” Koller said. “It’s going to be really critical to see how quickly the states react. There are going to be some states that will not.”

See the original article Here.


Hancok J. (2017 March 24). Late move to dump 'essential' benefits could strand chronically ill [Web blog post]. Retrieved from address https://khn.org/news/late-move-to-dump-essential-benefits-could-strand-chronically-ill/

CMS issues the final HHS Notice of Benefit and Payment Parameters for 2016

Originally posted on February 20, 2015 on www.cms.gov.

The Centers for Medicare & Medicaid Services (CMS) has issued the Final HHS Notice of Benefit and Payment Parameters for 2016.  This rule seeks to improve consumers’ experience in the Health Insurance Marketplace and to ensure their coverage options are affordable and accessible.  This rule builds on previously issued standards which seek to make high-quality health insurance available to all Americans.  The final notice further strengthens transparency, accountability, and the availability of information for consumers about their health plans.

“We work every day to strengthen programs that deliver quality, affordable care to families across the country,” said CMS Administrator Marilyn Tavenner.  “CMS is working to improve the consumer experience and promote accountability, uniformity, and transparency in private health insurance.”

The rule finalizes the annual open enrollment period for 2016 to begin on November 1, 2015 and run through January 31, 2016, giving consumers three full months to shop.  To further aid consumers in finding a health plan that best suits their needs, the rule clarifies standards for qualified health plan (QHP) issuers to publish up-to-date, accurate, and complete provider directories and formularies.  Issuers also must make this information available in standard, machine-readable formats.

To enhance the transparency of the rate-setting process, the final rule includes provisions to facilitate public access to information about rate increases in the individual and small group markets for both QHPs and non-QHPs using a uniform timeline.  It also includes provisions to further protect consumers against unreasonable rate increases by ensuring more rates are subject to review.

To ensure consumers have access to high-quality, affordable health insurance, premium stabilization programs were put in place to promote price stability for health insurance in the individual and small group markets.  This rule includes additional provisions and modifications related to the implementation of these programs, as well as the key payment parameters for the 2016 benefit year.

Additionally, the rule will help consumers access the medications they need by improving the process by which an enrollee can request access to medications not included on a plan’s formulary.  The rule provides more detailed procedures for the standard exception process, and adds a requirement for an external review of an exception request if the health plan denies the initial request.  It also clarifies that cost-sharing for drugs obtained through the exceptions process must count toward the annual limitation on cost sharing of a plan subject to the essential health benefits requirement.  The rule also ensures that issuers’ formularies are developed based on expert recommendations.

The rule improves meaningful access standards by requiring that all Marketplaces, QHP issuers, and web brokers provide telephonic interpreter services in at least 150 languages in addition to the existing requirements regarding the provision of oral interpretation services, and strengthens other requirements related to language access.

To enhance the consumer experience for the Small Business Health Options Program (SHOP), the rule seeks to streamline the administration of group coverage provided through SHOP and to align SHOP regulations with existing market practices.

The final rule was placed on display at the Federal Register today, and can be found at:


CMS also released its final annual letter to issuer, which provides additional guidance on these and related standards for plans participating in the Federally-facilitated Marketplace.  The letter is available here:https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/2016-PN-Fact-Sheet-final.pdf

Three PPACA Coverage Terms Explained

Source: United Benefit Advisors

The Patient Protection and Affordable Care Act (PPACA) uses terms that sound alike for three very different things.  Here’s a closer look at these terms, and when they’re used.

Essential Health Benefits
Significantly affects individuals and small employers with a fully insured plan.  Has a limited impact on self-funded and large insured plans.

Beginning in 2014, policies in the individual and small group markets* will be required to provide coverage for each of the 10 “essential health benefits” regardless whether the policy is purchased through or outside the exchange.  Self-funded plans (regardless of size), large group plans, and grandfathered plans (regardless of size) do not have to cover all 10 essential health benefits, but they will not be allowed to put lifetime or annual dollar limits on an essential health benefit.

Each state will have its own “benchmark” essential health benefits package. The essential health benefit categories are ambulatory/outpatient, emergency, hospitalization, maternity and newborn care, mental health and substance use, prescription drugs, rehabilitative and habilitative services and devices (for example, speech, physical and occupational therapy), laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including pediatric dental and vision care.

Minimum Essential Coverage
Affects most individuals and all employers with 50 or more employees (regardless whether its plan is self-funded or fully insured).

Beginning in 2014, most Americans will be required to have “minimum essential coverage” or pay a penalty with their tax return. (In 2014, the penalty will be the greater of 1 percent of income or $95.)  A person will have minimum essential coverage if he or she is covered under an eligible employer-sponsored plan, an individual policy (through or outside the exchange), or a government plan (Medicare, Medicaid, CHIP, TRICARE, VA, etc.).

Also beginning in 2014, employers with 50 or more full-time or full-time equivalent employees will be required to offer minimum essential coverage to nearly all of their employees who work 30 or more hours a week, or pay a penalty.  (If minimum essential coverage isn’t offered to at least 95 percent of full-time employees and their dependent children, a penalty of $2,000 per year per full-time employee, excluding 30 full-time employees, will apply.)

A clear definition of “minimum essential coverage” for employer-provided benefits has not been provided yet, but it appears that fairly basic medical coverage will be enough.  “Eligible employer-sponsored coverage” includes any plan offered in the small or large group market in a state, as well as self-funded plans, unless the plan only provides “excepted benefits.”  Excepted benefits are those that provide very limited medical coverage, like hospital indemnity, long-term care and cancer plans, on-site medical clinics, disability income and accident plans, and dental- and vision-only coverage.  Plans with annual dollar limits on essential health benefits will not be allowed after 2014, so it is unlikely that a standalone HRA will provide minimum essential coverage.

Minimum Value Coverage
Affects employers with 50 or more employees (regardless whether its plan is self-funded or fully insured) and individuals who may be eligible for premium tax credits/subsidies.

Beginning in 2014, employers with 50 or more full-time or full-time equivalent employees that offer coverage that is less than “minimum value” will have to pay a penalty.  (The penalty for not providing minimum value, affordable coverage is $3,000 for each full-time employee who obtains coverage through a public exchange and receives a premium tax credit/subsidy.  Individuals will not be eligible for a subsidy if their employer offers them affordable, minimum value coverage.)

Minimum value coverage is coverage with an actuarial value of at least 60 percent – this means that on average the plan is designed to pay at least 60 percent of covered charges.  (The employee would be responsible for the other 40 percent through the deductible, copays and coinsurance.)  In the self-funded and large markets, employers will be able to use a calculator provided by the government, and possibly safe harbor plan designs, to make sure their plan meets the 60 percent standard.  The proposed calculator can be found here (under the “Plan Management” section, look for Feb. 20, 2013 / Minimum Value Calculator): Regulations and Guidance | cciio.cms.gov.  According to HHS, 97 percent of the employer-sponsored plans they surveyed already meet the 60 percent requirement.

In the individual and small group markets, a “bronze” policy will have an actuarial value of 60 percent.

In a nutshell, then:

  • Essential health benefits are the kinds of care small plans must cover
  • Minimum essential coverage is what individuals must have and large employers must offer if they don’t want to pay tax penalties
  • Minimum value coverage is what large employers must offer to avoid a different tax penalty

 * It is still unclear what size makes a plan “large” or “small” under the essential health benefits rules.  Clearly, a plan with fewer than 50 employees is “small” and a plan with more than 100 employees is “large.”  States have the option to consider plans below 100 as “small” until 2016, but it is not clear yet how they make that choice.  (It is clear that a plan is “large” under the minimum essential and minimum value requirements if there are 50 or more full-time or full-time equivalent employees in its control group.)


Highlights of Rules on Essential Health Benefits and Actuarial Value

On Nov. 20, 2012, the Department of Health and Human Services (HHS) issued a proposed rule that addresses a number of questions surrounding essential health benefits and determining actuarial and minimum value.  This rule is still in the "proposed" stage, which means that there may - and likely will - be changes when the final rules are issued.

Provisions that Particularly Affect Insured Small Employers
Beginning in 2014, nongrandfathered insurance coverage in the individual and small group markets will be required to provide coverage for "essential health benefits" (EHBs) at certain levels of coverage.  The proposed rule:

  • Confirms that these policies, whether provided through or outside of an exchange, will be required to:
    • cover the 10 essential health benefits:
      • ambulatory/outpatient
      • emergency
      • hospitalization
      • maternity and newborn care
      • mental health and substance use
      • prescription drugs
      • rehabilitative and habilitative services and devices - e.g., speech, physical and occupational therapy
      • laboratory services
      • preventive and wellness services and chronic disease management
      • pediatric services, including pediatric dental and vision care
    • provide coverage that meets the "metal" standards (an actuarial value of 60, 70, 80 or 90 percent; actuarial value means the percentage of allowed costs the plan is expected to pay for a standard population)
    • meet cost-sharing requirements (in most instances, the deductible for in-network services could not exceed $2,000 per person or $4,000 per family, and the out-of-pocket limit for in-network services could not exceed the high deductible health plan limit for health savings account eligibility, which is currently $6,050 per person or $12,100 per family)
  • Confirms that each state would choose its own EHB package, based on a "base-benchmark" plan already available in the state.  Many states have already chosen their base-benchmark plan; those who have not done so have until Dec. 26, 2012, to make their selection or the federal government will make the selection for them. Information on state elections to date and the policy that will apply if no choice is made is here: Additional Information on Proposed State Essential Health Benefits Benchmark Plans | cciio.cms.gov
  • Provides a way to cover any gaps in EHB coverage under the base-benchmark plan (because many plans do not currently cover habilitative care or pediatric vision / dental services)
  • Provides that other policies in the exchange and small-group market must generally provide the same coverage within each EHB category as the base-benchmark plan, but that they may substitute an actuarially equivalent benefit within a category
  • States that HHS will provide a calculator that must be used in most situations to determine actuarial value
  • Provides that a plan that is within 2 percent of the metal standard would be acceptable (for instance, a plan with an actuarial value of 68 percent to 72 percent would be considered a "silver" plan)
  • Provides that state mandates in place as of Dec. 31, 2011, would be considered EHBs
  • Provides that current year employer contributions to a health savings account (HSA) or a health reimbursement arrangement (HRA) would be considered as part of the actuarial value calculation

Provisions that Particularly Affect Self-Funded and Large Employers

For the most part, self-funded and large-group plans would not be required to provide coverage for each of the 10 EHB categories.  However, these plans would not be allowed to impose annual dollar limits on EHBs. Also, although self-funded and large-group plans would not be required to cover all of the EHBs, they would be required to provide coverage for all of the "core" benefits -- hospital and emergency care, physician and mid-level practitioner care, pharmacy, and laboratory and imaging - to be considered a plan that provides "minimum value."
The proposed rule also:
  • States that HHS and the IRS would provide a minimum value calculator and safe harbor plan designs that self-funded and large-group plans could use to determine whether the plan provides minimum value (the safe harbor plan designs were not included in the proposed rule)
  • Provides that current-year employer contributions to an HSA or a HRA would be considered as part of the minimum value calculation
  • Resolves an ambiguity in the law and provides that the restrictions on maximum deductibles would not apply to self-funded and large-employer plans.
Important: This rule is still in the "proposed" stage, which means that there may be changes when the final rule is issued.  The public may make suggestions until Dec. 26, 2012, on how the proposed rule should be changed before it is finalized.  Employers should view the proposed rule as an indication of how plans will be regulated beginning in 2014, but need to understand that changes are entirely possible.