10 Essential [Mandated] Health Benefits (EBH) under Health Care Reform, PPACA

ACA Obamacare Essential Benefits
(A) Ambulatory patient services.
(D) Maternity (page 9 & 85)  [but not infertility] and newborn care.
NAMI Website , AB 88, CFR 156.115 (a) (3), “Federal Mental Health”  Mental Health Parity Act 1996   2008 Final Rules
(I) Preventive and wellness services and chronic disease management.
(J) Pediatric services, including oral and vision careBlue Shield Individual Flyer  Essential Health Benefits 5.2013         Group  Essential Health Benefits      (EBH) 42  USC  18022  SB 951

CA Essential Benefits

  • Preventive services for children 16 and younger
  • Mental health parity
  • Autism care including behavioral health treatment
  • Prescription drug coverage for contraceptives
  • Maternity hospital stay
  • Maternity: Inpatient hospital and ambulatory
  • AIDS vaccine
  • HIV testing
  • Organ transplants for HIV
  • Diabetes education, management and treatment
  • Alpha feto protein testing
  • Prosthetics for laryngectomy
  • Reconstructive surgery
  • Mastectomies and lymph node dissections
  • Mammography
  • Cervical cancer treatment
  • Cancer screening tests
  • Cancer clinical trials
  • Prostate cancer treatment
  • Osteoporosis treatment
  • Surgical procedures for jaw bones
  • Anesthesia for dental
  • Conditions attributable to diethylstilbestrol
  • Hospice (end of life) care
  • Pain management medication for terminally ill
  • Emergency response ambulance or ambulance transport services
  • Phenylketonuria treatment
  • Sterilization operations and procedures   View the Affordable  health ca.com page  Assembly Bill 1453 (Monning) and Senate Bill 951 (Hernandez).   View the California Health and Safety Code, section 1367.005
CMS proposes rule to allow states more latitude in defining essential benefits. Modern Health Care 10.27.2017  *  Considering how many extra benefits CA has, I doubt CA will lower any benefits.
States can get waivers exempting insurers from providing consumers with required coverage of specified health services, including hospital and outpatient care, pregnancy and mental health treatment. New York Times 5.5.2017
Six changes Trump can still make to ACA NPR 3.29.2017 
What might be lost under Donald Care?    CA Healthline 2.22.2017

2014 179 Page EOC Evidence of Coverage – So you can see EXACTLY how the above 10 benefits have been incorporated into the NEW plans Please note that these “essential benefits” do NOT  include income replacement if you can’t work, long term care, adult dental & vision or   life insurance! California Benchmarks ♦

Kaiser HMO 30 (1 Page)   CA SB 43 effective 1.1.2016 makes this the benchmark for individual plans too.

2 Page

all plans brochure (30 Pages),  

Evidence of Coverage 64 pages

2014 3 page Uniform Health Plan Benefits and Coverage Matrix with our annotations…

Different Benchmarks for each State makes the benefits differ nationwide  CA Healthline 10.23.2014

 Here’s the Feb. 20, 2013  final.rule establishing the essential health benefits (EHBs) for 10 categories of care, including basic services such as hospitalization and emergency care, as well as mental health and maternity care. In addition, the plans must cover a minimum of 60 percent of the actuarial value of covered medical services.

Arnold & Porter LLP 6 page summary of Final Rule

Affordable Care Act Will Expand Mental Health and Substance Use Disorder Benefits and Parity Protections for 62 Million Americans, that details how EHBs will expand mental health and substance use disorder benefits and federal laws requiring that mental health benefits be equal to, or have “parity” with, other health benefits in the individual and small group markets. .bna.com/hhs-releases-essential-n17179872551/

Guidence –  Bulletins Rules CMS.Gov

View the details and background of Essential Benefits on SteveShorr.com   Future updates will be on this site.

 Secretary of Health Kathleen Sebelius issued a set of defined “essential health benefits”[22] that all new insurance plans have to include. Insurers will be prohibited from imposing annual or lifetime coverage caps on these essential benefits.[191][195] These cover: “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; and pediatric services, including oral and vision care.”[196][197] In determining what would qualify as an essential benefit, the law required that the scope of standard benefits should equal that of a “typical employer plan”.[196] States have some discretion in determining what should be considered the benchmark plan within the requirements of the law, and may include services beyond those set out by the Secretary.[198]

Among the essential health benefits, preventive care, childhood immunizations and adult vaccinations, and medical screenings will be covered by an insurance plan’s premiums, and have co-payments, co-insurance, and deductibles eliminated.[199][200] Specific examples of such services covered include: mammograms and colonoscopies, wellness visits, gestational diabetes screening, HPV testing, STI counseling, HIV screening and counseling, FDA-approved contraceptive methods, breastfeeding support and supplies, and domestic violence screening and counseling.[201]  Wikipedial

Subpart B—Essential Health Benefits Package

Proposed Changes  CMS 9930 P  10.27.2017 §156.100   State selection of benchmark. §156.105   Determination of EHB for multi-state plans. §156.110   EHB-benchmark plan standards. §156.115   Provision of EHB. §156.120   Collection of data to define essential health benefits. §156.122   Prescription drug benefits. §156.125   Prohibition on discrimination. §156.130   Cost-sharing requirements. §156.135   AV calculation for determining level of coverage. §156.140   Levels of coverage. §156.145   Determination of minimum value. §156.150   Application to stand-alone dental plans inside the Exchange. §156.155   Enrollment in catastrophic plans.

8 comments on “10 Essential Benefits + CA Benefits

  1. Good morning-

    I got your name off the internet and was wondering if you can help me. I had Kaiser a few years ago. I need to get a detailed coverage guide for the attached plan. [ $30 Co-Pay Plan]

    Is this something you can help me with?

    Thank you-

    Marilyn D

    • You’ve lucked out on this question, as the Kaiser plan was selected as a Health Care Reform Bench Mark Plan. See links above. If they are not your exact plan, try our individual Kaiser historical page. If that still doesn’t work, we can help you at $125/hour and track it down somewhere, somehow. Do you still have Kaiser? Have you written to Kaiser to request it? Kaiser may hassle us, as you were not our client at the time. Kaiser doesn’t like to give out details. A lot of information though is on their website…???

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