Affordable Care Act Coverage Requirements
To stay ACA compliant, individual, employer group, and association health plans must focus on key compliance requirements. One critical factor involves understanding the requirement to offer essential health benefits. However, not all essential health benefits may be required for full ACA compliance. Therefore, plans must review which benefits apply based on their type and state regulations.
Essential Health Benefits and ACA Compliance:
However, most large employer group plans still offer essential health benefits to stay competitive and attract top talent. Moreover, they provide robust healthcare coverage to support employee retention and satisfaction.
- 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.
- Pediatric services, including oral and vision care
Requirement for Small and Large Employer Groups:
While all individual and group plans must follow ACA rules, essential health benefit requirements vary under ERISA guidelines. Moreover, small and large employer plans must review ERISA to understand which essential benefits apply to their plan type.
Small Group Health Plans: Small group health plans need not offer all ten essential benefit categories.
However, the ACA requires coverage in each of the ten statutory categories. This means small group plans must include benefits from each category, not every individual benefit. Additionally, states may 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. Most large employer group plans still offer essential health benefits to stay competitive and attract top talent. Moreover, they provide robust healthcare coverage to support employee retention and satisfaction.
Maternity Coverage and Essential Health Benefits:
Maternity and newborn care falls under the ten essential health benefit categories. While individual ACA plans must include maternity coverage, employer group plan requirements vary by state and plan type. Therefore, state laws and mandates often determine if employer group plans must offer maternity coverage. Consequently, employers should consult state regulations and insurance carriers to confirm maternity coverage requirements.
Remaining ACA Compliant:
To maintain ACA compliance, employer and association health plans should take the following proactive steps:
First, consult legal and insurance experts to understand state-specific essential health benefit requirements based on your plan type.
Next, review applicable state regulations to determine minimum mandates for essential health benefits and maternity coverage.
Then, communicate directly with insurance carriers to confirm all essential health benefits and maternity coverage details in your plan.
Additionally, stay informed about changes in healthcare laws to ensure continuous ACA compliance.
Finally, partner with Enrollment First, Inc. for expert compliance support and access to ACA-compliant coverage solutions for brokers and employers.
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