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

 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.

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
  • Medicare Coverage # 11021
• 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}

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}

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

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!

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.

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