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{{Health care reform in the United States}}
{{Health care reform in the United States}}
'''Essential health benefits''' ('''EHBs''') have been defined since the 2010 United States [[Affordable Care Act]] as a set of benefits which [[Individually purchased health insurance in the United States]] and insurance plans in small group markets, both inside and outside of the [[Health Insurance Marketplace]] must cover for people.<ref name="LalliAARP">Frank Lalli, [http://www.aarp.org/health/health-insurance/info-08-2013/affordable-care-act-health-benefits.html The Health Care Law's 10 Essential Benefits: The Affordable Care Act ensures you'll have access to these medical and wellness services], ''[[AARP The Magazine]]'' (August/September 2013).</ref>
'''Essential health benefits''' ('''EHBs''') have been defined since the 2010 United States [[Affordable Care Act]] as a set of benefits which [[Individually purchased health insurance in the United States]] and insurance plans in small group markets, both inside and outside of the [[Health Insurance Marketplace]] must cover for people.
⚫
Exempt from the EHB requirement are large-group health plans, self-insured [[Employee Retirement Income Security Act|ERISA]] plans, and ERISA-governed multiemployer welfare arrangements not subject to state insurance law.<ref>Rosenbaum, Teitelbaum & Hayes, p. 3.</ref>

⚫
Essential health benefits must be offered by health plans in .<ref name="HealthCare.gov">[https://www.healthcare.gov/glossary/essential-health-benefits/ Essential Health Benefits], HealthCare.gov (accessed November 12, 2015).</ref><ref>Rosenbaum, Teitelbaum & Hayes, p. 2.</ref> Large-group health plans, self-insured [[Employee Retirement Income Security Act|ERISA]] plans, and ERISA-governed multiemployer welfare arrangements not subject to state insurance law are exempt from the EHB requirement.<ref>Rosenbaum, Teitelbaum & Hayes, p. 3.</ref>


==Definition==
==Definition==

The 2010 [[Affordable Care Act]] (ACA) set forth the following ten categories of essential health benefits,<ref>[https://www.healthcare.gov/blog/10-health-care-benefits-covered-in-the-health-insurance-marketplace/ 10 health care benefits covered in the Health Insurance Marketplace], HealthCare.gov (accessed November 12, 2015).</ref><ref name="FamiliesUSA">Alexandra Ernst, [http://familiesusa.org/blog/10-essential-health-benefits-insurance-plans-must-cover-starting-in-2014 10 Essential Health Benefits Insurance Plans Must Cover Starting in 2014], FamiliesUSA (March 28, 2013).</ref> at Section 1302(b)(1) of the ACA, codified at [[Title 42 of the United States Code|42 U.S.C.]] § 18022(b):<ref>[https://www.law.cornell.edu/uscode/text/42/18022 42 U.S. Code § 18022 - Essential health benefits requirements]</ref>
The 2010 [[Affordable Care Act]] (ACA) set forth the following ten categories of essential health benefits,<ref>[https://www.healthcare.gov/blog/10-health-care-benefits-covered-in-the-health-insurance-marketplace/ 10 health care benefits covered in the Health Insurance Marketplace], HealthCare.gov (accessed November 12, 2015).</ref><ref name="FamiliesUSA">Alexandra Ernst, [http://familiesusa.org/blog/10-essential-health-benefits-insurance-plans-must-cover-starting-in-2014 10 Essential Health Benefits Insurance Plans Must Cover Starting in 2014], FamiliesUSA (March 28, 2013).</ref> at Section 1302(b)(1) of the ACA, codified at [[Title 42 of the United States Code|42 U.S.C.]] § 18022(b):<ref>[https://www.law.cornell.edu/uscode/text/42/18022 42 U.S. Code § 18022 - Essential health benefits requirements]</ref>


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==Requirement for which health insurance===
The 2010 [[Affordable Care Act]] (ACA) defines benefits which [[Individually purchased health insurance in the United States]] and insurance plans in small group markets, both inside and outside of the [[Health Insurance Marketplace]] must cover for people.<ref name="LalliAARP">Frank Lalli, [http://www.aarp.org/health/health-insurance/info-08-2013/affordable-care-act-health-benefits.html The Health Care Law's 10 Essential Benefits: The Affordable Care Act ensures you'll have access to these medical and wellness services], ''[[AARP The Magazine]]'' (August/September 2013).</ref><ref name="HealthCare.gov">[https://www.healthcare.gov/glossary/essential-health-benefits/ Essential Health Benefits], HealthCare.gov (accessed November 12, 2015).</ref> <ref>Rosenbaum, Teitelbaum & Hayes, p. 2.</ref> Exempt from the EHB requirement are large-group health plans, self-insured [[Employee Retirement Income Security Act|ERISA]] plans, and ERISA-governed multiemployer welfare arrangements not subject to state insurance law.<ref>Rosenbaum, Teitelbaum & Hayes, p. 3.</ref>
===Interpretation===
The essential health benefits are a minimum federal standard and "states may require that qualified health plans sold in state health insurance exchanges also cover state-mandated benefits."<ref>Rosenbaum, Teitelbaum & Hayes, p. 3.</ref>
The essential health benefits are a minimum federal standard and "states may require that qualified health plans sold in state health insurance exchanges also cover state-mandated benefits."<ref>Rosenbaum, Teitelbaum & Hayes, p. 3.</ref>
The act gives "considerable discretion" to the [[Secretary of Health and Human Services]] to determine, through regulation, what specific services within these classes are essential. However, the Act provides certain parameters for the secretary to consider. The secretary (1) must "ensure that such essential health benefits reflect an appropriate balance among the categories ... so that benefits are not unduly weighted toward any category"; (2) may "not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life"; (3) must take into account "the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups"; and (4) must ensure that essential benefits "not be subject to denial to individuals against their wishes on the basis of the individuals’ age or expected length of life or the individuals' present or predicted disability, degree of medical dependency, or quality of life."<ref>Rosenbaum, Teitelbaum & Hayes, pp. 3-4</ref>
The act gives "considerable discretion" to the [[Secretary of Health and Human Services]] to determine, through regulation, what specific services within these classes are essential. However, the Act provides certain parameters for the secretary to consider. The secretary (1) must "ensure that such essential health benefits reflect an appropriate balance among the categories ... so that benefits are not unduly weighted toward any category"; (2) may "not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life"; (3) must take into account "the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups"; and (4) must ensure that essential benefits "not be subject to denial to individuals against their wishes on the basis of the individuals’ age or expected length of life or the individuals' present or predicted disability, degree of medical dependency, or quality of life."<ref>Rosenbaum, Teitelbaum & Hayes, pp. 3-4</ref>
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{{quote|As it stands, federal regulations for 2014 and 2015 do not establish a single, nationally uniform package of health services. Instead, the U.S. Department of Health and Human Services (HHS) gave states discretion to determine the specific benefits they deem essential. This approach was well-received by many state officials, who valued the opportunity to tailor benefit standards to reflect state priorities, and by insurers, who retained more control over benefit design. Groups representing consumers and providers were less supportive, however, expressing concern that the degree of flexibility found in the rules undermines the law's promise of consistent, meaningful coverage.<ref>Giovannelli, Lucia & Corlette, p. 2.</ref>}}
{{quote|As it stands, federal regulations for 2014 and 2015 do not establish a single, nationally uniform package of health services. Instead, the U.S. Department of Health and Human Services (HHS) gave states discretion to determine the specific benefits they deem essential. This approach was well-received by many state officials, who valued the opportunity to tailor benefit standards to reflect state priorities, and by insurers, who retained more control over benefit design. Groups representing consumers and providers were less supportive, however, expressing concern that the degree of flexibility found in the rules undermines the law's promise of consistent, meaningful coverage.<ref>Giovannelli, Lucia & Corlette, p. 2.</ref>}}


==History==
==Law history==
Coverage of essential health benefits was first required by the [[Patient Protection and Affordable Care Act]] (PPACA or ACA) of 2010, which was a major piece of [[Health care reform in the United States|health care reform]] legislation.<ref name="LalliAARP" /> The EHB provisions of the ACA was an amendment to the [[Public Health Service Act]].<ref>Rosenbaum, Teitelbaum & Hayes, p. 2.</ref>
Coverage of essential health benefits was first required by the 2010 [[Patient Protection and Affordable Care Act]] (PPACA or ACA), which was a major piece of [[Health care reform in the United States|health care reform]] legislation.<ref name="LalliAARP" /> The EHB provisions of the ACA was an amendment to the [[Public Health Service Act]].<ref>Rosenbaum, Teitelbaum & Hayes, p. 2.</ref>
⚫
Lavarreda, director of health insurance studies for the [[University of California, Los Angeles|UCLA]] Center for Health Policy Research, explained that before the ACA's passage, U.S. health insurance sector experienced "a [[race to the bottom]], with insurers cutting benefits to lower premiums."<ref name="LalliAARP" /> The establishment of essential health benefits "set a standard for insurance. Anything below that is not true health insurance."<ref name="LalliAARP" /> The EHB requirement came into effect on January 1, 2014.<ref name="LalliAARP" />

⚫
Dr. Shana Alex Lavarreda, the director of health insurance studies for the [[University of California, Los Angeles|UCLA]] Center for Health Policy Research, explains that before the ACA's passage, U.S. health insurance sector experienced "a [[race to the bottom]], with insurers cutting benefits to lower premiums."<ref name="LalliAARP" /> The establishment of essential health benefits "set a standard for insurance. Anything below that is not true health insurance."<ref name="LalliAARP" /> The EHB requirement came into effect on January 1, 2014.<ref name="LalliAARP" />


Revision and repeal of essential health benefits coverage was proposed in the Republican part [[American Health Care Act of 2017]].<ref>{{Cite news|url=http://www.businessinsider.com/ahca-essential-health-benefits-ehb-2017-3|title=Republicans may gut an overlooked provision of Obamacare — and disrupt health insurance|work=Business Insider|access-date=2017-03-26|language=en}}</ref> House [[Freedom Caucus]] members lobbied during legislation discussion with House Speaker [[Paul Ryan]] to remove EHBs as a condition for approval of the AHCA bill.<ref>{{Cite web|url=http://www.cnn.com/2017/03/22/politics/essential-health-benefits-obamacare-freedom-caucus/index.html|title=Essential Health Benefits and why they matter|last=Luhby|first=Tami|website=CNN|access-date=2017-03-26}}</ref>
Revision and repeal of essential health benefits coverage was proposed in the Republican part [[American Health Care Act of 2017]].<ref>{{Cite news|url=http://www.businessinsider.com/ahca-essential-health-benefits-ehb-2017-3|title=Republicans may gut an overlooked provision of Obamacare — and disrupt health insurance|work=Business Insider|access-date=2017-03-26|language=en}}</ref> House [[Freedom Caucus]] members lobbied during legislation discussion with House Speaker [[Paul Ryan]] to remove EHBs as a condition for approval of the AHCA bill.<ref>{{Cite web|url=http://www.cnn.com/2017/03/22/politics/essential-health-benefits-obamacare-freedom-caucus/index.html|title=Essential Health Benefits and why they matter|last=Luhby|first=Tami|website=CNN|access-date=2017-03-26}}</ref>


==Comparison with minimum essential coverage==
==Comparison with minimum essential coverage==

Revision as of 06:58, 22 June 2017

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Essential health benefits (EHBs) have been defined since the 2010 United States Affordable Care Act as a set of benefits which Individually purchased health insurance in the United States and insurance plans in small group markets, both inside and outside of the Health Insurance Marketplace must cover for people. Exempt from the EHB requirement are large-group health plans, self-insured ERISA plans, and ERISA-governed multiemployer welfare arrangements not subject to state insurance law.[1]

Definition

The 2010 Affordable Care Act (ACA) set forth the following ten categories of essential health benefits,[2][3] at Section 1302(b)(1) of the ACA, codified at 42 U.S.C. § 18022(b):[4]

  1. Ambulatory patient services. [outpatient care]
  2. Emergency services.
  3. Hospitalization. [inpatient care]
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment.
  6. Prescription drugs.
  7. Rehabilitative and habilitative services and devices.
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management;
  10. Pediatric services, including oral and vision care.

Requirement for which health insurance=

The 2010 Affordable Care Act (ACA) defines benefits which Individually purchased health insurance in the United States and insurance plans in small group markets, both inside and outside of the Health Insurance Marketplace must cover for people.[5][6] [7] Exempt from the EHB requirement are large-group health plans, self-insured ERISA plans, and ERISA-governed multiemployer welfare arrangements not subject to state insurance law.[8]

Interpretation

The essential health benefits are a minimum federal standard and "states may require that qualified health plans sold in state health insurance exchanges also cover state-mandated benefits."[9] The act gives "considerable discretion" to the Secretary of Health and Human Services to determine, through regulation, what specific services within these classes are essential. However, the Act provides certain parameters for the secretary to consider. The secretary (1) must "ensure that such essential health benefits reflect an appropriate balance among the categories ... so that benefits are not unduly weighted toward any category"; (2) may "not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life"; (3) must take into account "the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups"; and (4) must ensure that essential benefits "not be subject to denial to individuals against their wishes on the basis of the individuals’ age or expected length of life or the individuals' present or predicted disability, degree of medical dependency, or quality of life."[10]

According to a Commonwealth Fund report in 2011:

As it stands, federal regulations for 2014 and 2015 do not establish a single, nationally uniform package of health services. Instead, the U.S. Department of Health and Human Services (HHS) gave states discretion to determine the specific benefits they deem essential. This approach was well-received by many state officials, who valued the opportunity to tailor benefit standards to reflect state priorities, and by insurers, who retained more control over benefit design. Groups representing consumers and providers were less supportive, however, expressing concern that the degree of flexibility found in the rules undermines the law's promise of consistent, meaningful coverage.[11]

Law history

Coverage of essential health benefits was first required by the 2010 Patient Protection and Affordable Care Act (PPACA or ACA), which was a major piece of health care reform legislation.[5] The EHB provisions of the ACA was an amendment to the Public Health Service Act.[12] Lavarreda, director of health insurance studies for the UCLA Center for Health Policy Research, explained that before the ACA's passage, U.S. health insurance sector experienced "a race to the bottom, with insurers cutting benefits to lower premiums."[5] The establishment of essential health benefits "set a standard for insurance. Anything below that is not true health insurance."[5] The EHB requirement came into effect on January 1, 2014.[5]

Revision and repeal of essential health benefits coverage was proposed in the Republican part American Health Care Act of 2017.[13] House Freedom Caucus members lobbied during legislation discussion with House Speaker Paul Ryan to remove EHBs as a condition for approval of the AHCA bill.[14]

Comparison with minimum essential coverage

Essential health benefits should not be confused with minimum essential coverage (MEC). MEC is the minimum amount of coverage that an individual must carry to meet the individual health insurance mandate, while EHBs are a set of benefits that qualified health plans (QHPs) must offer.[15] MEC is a low threshold; many forms of coverage that do not provide essential health benefits are nevertheless considered minimum essential coverage.[15]

Notes

  1. ^ Rosenbaum, Teitelbaum & Hayes, p. 3.
  2. ^ 10 health care benefits covered in the Health Insurance Marketplace, HealthCare.gov (accessed November 12, 2015).
  3. ^ Alexandra Ernst, 10 Essential Health Benefits Insurance Plans Must Cover Starting in 2014, FamiliesUSA (March 28, 2013).
  4. ^ 42 U.S. Code § 18022 - Essential health benefits requirements
  5. ^ a b c d e Frank Lalli, The Health Care Law's 10 Essential Benefits: The Affordable Care Act ensures you'll have access to these medical and wellness services, AARP The Magazine (August/September 2013).
  6. ^ Essential Health Benefits, HealthCare.gov (accessed November 12, 2015).
  7. ^ Rosenbaum, Teitelbaum & Hayes, p. 2.
  8. ^ Rosenbaum, Teitelbaum & Hayes, p. 3.
  9. ^ Rosenbaum, Teitelbaum & Hayes, p. 3.
  10. ^ Rosenbaum, Teitelbaum & Hayes, pp. 3-4
  11. ^ Giovannelli, Lucia & Corlette, p. 2.
  12. ^ Rosenbaum, Teitelbaum & Hayes, p. 2.
  13. ^ "Republicans may gut an overlooked provision of Obamacare — and disrupt health insurance". Business Insider. Retrieved 2017-03-26.
  14. ^ Luhby, Tami. "Essential Health Benefits and why they matter". CNN. Retrieved 2017-03-26.
  15. ^ a b Susan Grassli & Lisa Klinger, Understanding the Difference between Minimum Essential Coverage, Essential Health Benefits, Minimum Value, and Actuarial Value, Leavitt Group (January 27, 2014).

Sources

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