Compliance

The Affordable Care Act (ACA) presents many new compliance challenges that range from ensuring plan designs incorporate the required benefits to notifying employee’s about the public Exchange.

Essential Health Benefits

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Beginning on January 1, 2014, the Affordable Care Act requires all non-grandfathered individual and small group health plans to cover essential health benefits (EHB).  Group health plans in the large group market plus self-insured and grandfathered plans are not required to cover EHB.

EHB includes items and services in the following ten categories of benefits:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • 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 oral and vision care

Each state was required to select a benchmark plan to be used to determine the EHB for the state.  California is using the Kaiser Small Group HMO 30 plan as its benchmark plan.

While large group and self-insured plans are not required to cover EHB, those plans that do cover EHB may not place annual or lifetime dollar limit on the value of those benefits.  Additional information on EHB and the prohibition against lifetime or annual dollar limits on EHB can be found below.

 

 

Additional Information
Health Care Reform: Essential Health Benefits Guidance
This Briefing outlines guidance from the Department of Health and Human Services on how to define Essential Health Benefits.
Prohibition on Lifetime and Annual Dollar Limits