518-373-4111
Under the Affordable Care Act (ACA), health insurance sold to small employers (that is, those with up to 50 employees), for plans that begin on or after January 1, 2014, must cover the 10 required essential health benefits defined under law.
This requirement kicks in on the first day of plan years which begin on or after January 1, 2014. Certain “grandmothered” plans get a one-year reprieve or even longer (“grandmothered” plans, also known as “transitional renewal plans,” are those that existed on October 1, 2013 and are renewed prior to October 1 this year).
The essential health benefits requirement leaves insurance carriers with limited room for flexibility in design and pricing. In contrast, self-insured employers must meet ACA’s broader value and affordability tests, based on the metallic scale (with platinum plans covering the most, and bronze plans covering the bare minimum).
The following benefits must be covered in “fully insured” health plans offered by employers with less than 100 employees:
- Ambulatory patient services (outpatient care you get without being admitted to a hospital)
- Emergency services
- Hospitalization (such as surgery)
- Maternity and newborn care (care before and after your baby is born)
- Mental health and substance use disorder services, including behavioral health treatment (this includes counseling and psychotherapy)
- Prescription drugs
- Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services
For more information, please contact GTM’s Insurance Experts at (518) 373-4111.
