CMS announced it has passed a new rule aimed at providing
states and insurers with more flexibility in implementing the Affordable Care Act.
Consumers will have a consistent way to compare and enroll
in health coverage in the individual and small group markets. This will make it easier for consumers to
purchase insurance that will provide better quality, and expanded coverage and
benefits.
Key Points are:
·
A core package of “Essential Health Benefits”
has been developed that must include items and services within
at least the following 10 categories:
1. Ambulatory
patient services
2. Emergency
services
3. Hospitalization
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
Note: Substance use disorder and behavioral health
services have had a history of falling into the gap of coverage for millions of
Americans. The rule seeks to fix
that gap in coverage by expanding coverage of these benefits in three distinct
ways:
o By
including mental health and substance use disorder benefits as Essential Health
Benefits.
o By
applying federal parity protections to mental health and substance use disorder
benefits in the individual and small group markets.
o By
providing more Americans with access to quality health care that includes
coverage for mental health and substance use disorder services.
·
A benchmark-based approach is aimed at
giving states the flexibility to define essential health benefits in a way that
would best meet the needs of their residents. States are allowed to select
benchmark plan from options offered in the market, which are equal in scope to
a typical employer plan.
·
In the individual and small group
markets, four different actuarial value “metal levels” are outlined in the
final rule. Plans that cover essential
health benefits must cover a certain percentage of costs (actuarial
value): 60 percent for a bronze plan,
70 percent for a silver plan, 80 percent for a gold plan, and 90 percent for a
platinum plan. These ”metal levels” will allow consumers to compare
insurance plans with similar levels of coverage and cost-sharing based on
premiums, provider networks, and other factors
·
The annual amount of cost sharing that individuals
will pay across all health plans (preventing insured Americans from facing
catastrophic costs associated with an illness or injury) has been limited by
this law.
Note: While not yet set for 2014, the comparable
limit this year is $6,250 for self-only coverage.
·
Accreditation standards for qualified health plans (QHPs)
that will be offered through the Health
Insurance Marketplaces (also known as Exchanges)
are more clearly defined in the final rule.
The Exchanges will be reliable one-stop shops that will provide access
to quality, affordable private health insurance choices.
For more information from CMS on this
rule, visit:
To view the rule, visit:
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