The Department of Health and Human Services issues a final rule on the essential health benefits required of insurers under the Patient Protection and Affordable Care Act. These benefits, defined by HHS as standards that the issuer must meet in their core package of health care coverage, will mainly affect individual and small group plans in both the private insurance and public exchange markets starting in January. The standards were widely in line with industry expectations following proposals in December.

“People all across the country will soon find it easier to compare and enroll in health plans with better coverage, greater quality and new benefits,” said Secretary Kathleen Sebelius in a statement released with the ruling. HHS highlights that the regulation most drastically affects mental health and substance abuse services.

According to HHS, almost 20% of individuals purchasing insurance did not have access to mental health coverage, and one third did not have substance abuse benefits. Standards were set by allowing states to set a benchmark “equal in scope to a typical employer plan” in the market or the feds set the benchmark by looking at the largest small business plan in the state. Twenty-six states elected to set their own benchmark and the rest were assigned by the feds.

The actuarial value levels in the individual and small group spaces are also finalized. HHS has categorized the different levels of cost coverage that the insurer must follow as:

  • Bronze: 60% coverage of costs
  • Silver: 70% coverage of costs
  • Gold: 80% coverage of costs
  • Platinum: 90% coverage of costs

Find the full rule from HHS here.

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