Learn About the Affordable Care Act

Essential Health Benefits Packages

Starting in 2014 The Affordable Care Act (ACA) requires individual and small group insurance plans to include an essential health benefits package. This:

  • Covers essential health benefits
  • Limits annual cost-sharing
  • Pays at least 60% of the cost of covered expenses

Essential health benefits include:

  • Doctor's office and clinic visits and tests
  • Emergency services
  • Hospital stays
  • Maternity and newborn care
  • Mental health and substance-use disorder services including treatment
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Lab services
  • Preventive and wellness services and chronic disease management
  • Children's health services including dental and vision care

The Secretary of Health and Human Services announced in December 2011 that each state will determine its own package.  The state must include the required services listed above and be based on a benchmark plan in the state.  The benchmark plans can be:

  • The largest HMO in the state's private market
  • The largest plan covering small businesses
  • The state employees plan
  • The federal employees plan in the state

If the state does not designate a benchmark plan, the standard will be the small business plan with the largest enrollment in the state.  

Limited Cost-Sharing

Cost-sharing is the part of your health care that you pay. This includes premiums, deductibles, co-insurance, and co-pays. In 2014, health insurance plans must limit these costs. They will:

  • Not make you pay more each year than you would for a high deductible plan
  • Limit small group plans to annual deductibles of $2,000 for individuals and $4,000 for families
  • Make the insurer pay 100% of preventive health services

Bronze, Silver, Gold, or Platinum Coverage Level

All health plans in 2014 must pay for at least 60% of the cost of covered medical services. The level provided is referred to as bronze (60%), silver (70%), gold (80%), or platinum (90%).

For more on Essential Health Benefits see the American Cancer Society's report.

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