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Essential Health Benefits Required for ACA Compliance

Essential Health Benefits Required for ACA Compliance

When it comes to remaining ACA compliant, individual health plans, employer group health plans and association health plans must pay attention to relevant items to ensure compliance. One essential aspect is understanding the requirement of offering essential health benefits. However, the question arises: are all essential health benefits necessary to be ACA compliant? 

Essential Health Benefits and ACA Compliance: 

Under the Affordable Care Act (ACA), health insurance plans are required to offer essential health benefits (EHBs) to be considered ACA compliant. These benefits aim to provide individuals and families with comprehensive coverage for essential healthcare needs. The ten categories of essential health benefits include: 

  1. Ambulatory patient services. 
  1. Emergency services. 
  1. Hospitalization. 
  1. Maternity and newborn care. 
  1. Mental health and substance use disorder services, including behavioral health treatment. 
  1. Prescription drugs. 
  1. Rehabilitative and habilitative services and devices. 
  1. Laboratory services. 
  1. Preventive and wellness services and chronic disease management. 
  1. Pediatric services, including oral and vision care. 

Requirement for Small and Large Employer Groups: 

While all individual, small group health plans (typically those covering 1-50 employees) and large employer group health plans (typically those covering 51 employees or more) must comply with certain ACA provisions, the requirement to offer essential health benefits varies as defined by ERISA. 

Small Group Health Plans: Small group health plans are not required to offer all ten categories of essential health benefits. However, the ACA requires that these plans provide coverage for “essential health benefits in each of 10 statutory categories.” It means small group plans must offer coverage in each category but are not obligated to provide every benefit within the category. States also have the flexibility to define specific standards for small group health plans. 

Large Employer Group Health Plans: Large employer group health plans are not specifically required to offer essential health benefits. Instead, they must meet certain minimum value and affordability standards per ERISA regulations. However, most large employer group plans still offer comprehensive coverage that includes the essential health benefits, as they aim to attract and retain top talent by providing robust healthcare benefits. 

Maternity Coverage and Essential Health Benefits: 

Maternity and newborn care is among the ten categories of essential health benefits. While individual ACA plans must include maternity coverage, whether employer group health plans, including small and large groups, are required to offer this benefit depends on the state and plan type. State laws, including state-specific mandates, influence the inclusion of maternity coverage in employer group health plans. Employers should consult their state regulations and insurance carriers to determine the exact requirements for maternity coverage in their group health plans. 

Remaining ACA Compliant: 

To ensure ACA compliance with their group health plans, employer group health plans and association health plans should consider the following: 

  1. Consult with Legal and Insurance Experts: Employers should consult legal counsel and insurance experts to understand the specific requirements of their state and plan type regarding essential health benefits. 
  1. Review State Regulations: Employers should thoroughly review state regulations and mandates to determine the minimum requirements for essential health benefits and maternity coverage. 
  1. Communicate with Insurance Carriers: Employers should communicate with their insurance carriers to clarify the coverage details, including the inclusion of essential health benefits and maternity coverage. 

It is essential to note that healthcare laws and regulations are subject to change, and employers should stay updated on any revisions or new requirements to maintain ACA compliance. Enrollment First, Inc. offers compliance support for insurance brokers and employers alike and helps with providing complaint coverage options. 

Sources: 

[1] Essential Health Benefits: https://www.healthcare.gov/glossary/essential-health-benefits/ 

[2] Small Business Health Options Program (SHOP) Marketplace: https://www.healthcare.gov/small-businesses/employers/coverage/ 

[3] Healthcare Exchange – Am I Required to Provide Maternity Coverage to My Employees?: https://www.healthcare-exchange.org/learn/requirements-responsibilities/am-i-required-to-provide-maternity-coverage-to-my-employees 

[4] What Employers Need to Know: https://www.reliascent.com/blog/what-small-employers-need-to-know-about-the-affordable-care-act-and-essential-benefits 

[5] Insurance Mandates and Essential Health Benefits: https://www.ncsl.org/research/health/essential-health-benefits-state-legislative-database.aspx