Impacts non-grandfathered small-group plans (both in and outside the exchange) beginning with the 2014 plan year:
Beginning with the 2014 plan year all nongrandfathered plans in the small group market – whether inside or outside the exchange – will need to provide the “essential health benefits package” (EHB package). The EHB package includes coverage for the 10 essential health benefits, at the metal levels, with permitted cost-sharing. The essential health benefits are coverage within these categories – 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, and pediatric services, including pediatric dental and vision care.
Each state will have its own benchmark plan, supplemented as needed to provide acceptable coverage in all 10 categories. The chosen benchmark plan will remain the benchmark for 2014 and 2015. (The selected benchmark plans are listed beginning on page 141 of the final Essential Health Benefits regulation; the link is at the end of this update.) Carriers may substitute an actuarially equivalent benefit within each category. Abortion services, including pharmaceuticals, do not need to be covered by any plan.
Small group plans, both in and outside the exchange, may only provide coverage at the metal levels. (A plan that is designed to cover 90 percent of covered costs is a platinum plan, a plan designed to cover 80 percent of covered costs is a gold plan, a 70 percent plan is a silver plan and a 60 percent plan is a bronze plan.) There will be a permitted variation of 2 percent so, for example, a silver plan would have an actuarial value of 68 to 72 percent. In addition, catastrophic plans may be offered both in and out of the exchanges to individuals aged 21 to 30 and to those who can prove financial hardship. The catastrophic plans must provide three first-dollar primary care visits per year, first dollar preventive coverage and coverage for the essential health benefits once the deductible (which must be at least $6,250 single and $12,500 family, indexed) is reached.
Cost-sharing (which will be based on in-network usage) will be limited to a deductible of $2,000 per person and $4,000 per family. However, bronze plans will be allowed to increase the deductible where necessary to meet actuarial value requirements (additional details on how this may be done will be provided). The out-of-pocket limit is the maximum out-of-pocket limit that may be in a high deductible health plan linked to a health savings account (currently $6,250 single and $12,500 family).Current year employer contributions to health reimbursement arrangements and health savings accounts are included in the actuarial value calculation. It does not appear they can be combined with the plan deductible to meet the $2,000/$4,000 limit.
The actuarial value calculator for small group plans has been finalized and is at: Regulations and Guidance | cciio.cms.gov
The text of the final rule on essential health benefits is here: http://www.ofr.gov/OFRUpload/OFRData/2013-04084_PI.pdf
