Beginning with plan years on or after January 1, 2014, annual and lifetime dollar limits on Essential Health Benefits (EHBs) are prohibited. However, other forms of cost containment, including day and/or visit limits, will continue to be allowed. This regulation applies to both non-grandfathered and grandfathered plans. The following categories of services are considered

Essential Health Benefits:

1. Ambulatory outpatient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services (that help patients acquire, maintain, or improve skills necessary for daily functioning) and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

PPACA requires each state, at a minimum, to identify a benchmark plan that includes services within the EHB categories above that are representative of the typical small employer plan in their state. Since states may choose among several different plan options in crafting their own benchmarks, each self-insured plan may designate a state benchmark plan of their choosing, which they then will use as a reference point in terms of identifying the EHBs offered underneath their own plans. Please be aware that self-funded plans are not required to cover any EHBs within their plans, but to the extent that they do, they cannot apply annual or lifetime dollar limits to those services.

Information on state benchmark plans can be located at http://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.

Disclaimer: The information contained herein is not intended to be legal advice, and while every effort has been made to ensure that the content of this legislative summary is accurate, we makes no representations or warranties in relation to the information provided, and assumes no liability or responsibility for any acts or omissions based on this information. As always, we encourage you to consult with your own legal counsel prior to making any decisions regarding plan design or administration.