42 USC 18022 - Essential health benefits requirements

U.S Code last checked for updates: Nov 22, 2024

§ 18022.

Essential health benefits requirements

(a)

Essential health benefits package

In this title,1

 See References in Text note below.

the term “essential health benefits package” means, with respect to any health plan, coverage that—

(1)

provides for the essential health benefits defined by the Secretary under subsection (b);

(2)

limits cost-sharing for such coverage in accordance with subsection (c); and

(3)

subject to subsection (e), provides either the bronze, silver, gold, or platinum level of coverage described in subsection (d).

(b)

Essential health benefits

(1)

In general

Subject to paragraph (2), the Secretary shall define the essential health benefits, except that such benefits shall include at least the following general categories and the items and services covered within the categories:

(A)

Ambulatory patient services.

(B)

Emergency services.

(C)

Hospitalization.

(D)

Maternity and newborn care.

(E)

Mental health and substance use disorder services, including behavioral health treatment.

(F)

Prescription drugs.

(G)

Rehabilitative and habilitative services and devices.

(H)

Laboratory services.

(I)

Preventive and wellness services and chronic disease management.

(J)

Pediatric services, including oral and vision care.

(2)

Limitation

(A)

In general

(B)

Certification

(3)

Notice and hearing

(4)

Required elements for consideration

In defining the essential health benefits under paragraph (1), the Secretary shall—

(A)

ensure that such essential health benefits reflect an appropriate balance among the categories described in such subsection,2

 So in original. Probably should be “paragraph,”.

so that benefits are not unduly weighted toward any category;

(B)

not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life;

(C)

take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups;

(D)

ensure that health benefits established as essential not be subject to denial to individuals against their wishes on the basis of the individuals’ age or expected length of life or of the individuals’ present or predicted disability, degree of medical dependency, or quality of life;

(E)

provide that a qualified health plan shall not be treated as providing coverage for the essential health benefits described in paragraph (1) unless the plan provides that—

(i)

coverage for emergency department services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the providing of services that is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan; and

(ii)

if such services are provided out-of-network, the cost-sharing requirement (expressed as a copayment amount or coinsurance rate) is the same requirement that would apply if such services were provided in-network;

(F)

provide that if a plan described in section 18031(b)(2)(B)(ii) 3

 So in original. Probably should be “18031(d)(2)(B)(ii)”.

of this title (relating to stand-alone dental benefits plans) is offered through an Exchange, another health plan offered through such Exchange shall not fail to be treated as a qualified health plan solely because the plan does not offer coverage of benefits offered through the stand-alone plan that are otherwise required under paragraph (1)(J); and 4

 So in original. The word “and” probably should not appear.

(G)

periodically review the essential health benefits under paragraph (1), and provide a report to Congress and the public that contains—

(i)

an assessment of whether enrollees are facing any difficulty accessing needed services for reasons of coverage or cost;

(ii)

an assessment of whether the essential health benefits needs to be modified or updated to account for changes in medical evidence or scientific advancement;

(iii)

information on how the essential health benefits will be modified to address any such gaps in access or changes in the evidence base;

(iv)

an assessment of the potential of additional or expanded benefits to increase costs and the interactions between the addition or expansion of benefits and reductions in existing benefits to meet actuarial limitations described in paragraph (2); and

(H)

periodically update the essential health benefits under paragraph (1) to address any gaps in access to coverage or changes in the evidence base the Secretary identifies in the review conducted under subparagraph (G).

(5)

Rule of construction

(c)

Requirements relating to cost-sharing

(1)

Annual limitation on cost-sharing

(A)

2014

(B)

2015 and later

In the case of any plan year beginning in a calendar year after 2014, the limitation under this paragraph shall—

(i)

in the case of self-only coverage, be equal to the dollar amount under subparagraph (A) for self-only coverage for plan years beginning in 2014, increased by an amount equal to the product of that amount and the premium adjustment percentage under paragraph (4) for the calendar year; and

(ii)

in the case of other coverage, twice the amount in effect under clause (i).

If the amount of any increase under clause (i) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50.

(2)

Repealed. Pub. L. 113–93, title II, § 213(a)(1), Apr. 1, 2014, 128 Stat. 1047

(3)

Cost-sharing

In this title— ¹

(A)

In general

The term “cost-sharing” includes—

(i)

deductibles, coinsurance, copayments, or similar charges; and

(ii)

any other expenditure required of an insured individual which is a qualified medical expense (within the meaning of section 223(d)(2) of title 26) with respect to essential health benefits covered under the plan.

(B)

Exceptions

(4)

Premium adjustment percentage

(d)

Levels of coverage

(1)

Levels of coverage defined

The levels of coverage described in this subsection are as follows:

(A)

Bronze level

(B)

Silver level

(C)

Gold level

(D)

Platinum level

(2)

Actuarial value

(A)

In general

(B)

Employer contributions

(C)

Application

(3)

Allowable variance

(4)

Plan reference

(e)

Catastrophic plan

(1)

In general

A health plan not providing a bronze, silver, gold, or platinum level of coverage shall be treated as meeting the requirements of subsection (d) with respect to any plan year if—

(A)

the only individuals who are eligible to enroll in the plan are individuals described in paragraph (2); and

(B)

the plan provides—

(i)

except as provided in clause (ii), the essential health benefits determined under subsection (b), except that the plan provides no benefits for any plan year until the individual has incurred cost-sharing expenses in an amount equal to the annual limitation in effect under subsection (c)(1) for the plan year (except as provided for in section 2713); ¹ and

(ii)

coverage for at least three primary care visits.

(2)

Individuals eligible for enrollment

An individual is described in this paragraph for any plan year if the individual—

(A)

has not attained the age of 30 before the beginning of the plan year; or

(B)

has a certification in effect for any plan year under this title ¹ that the individual is exempt from the requirement under section 5000A of title 26 by reason of—

(i)

section 5000A(e)(1) of such title (relating to individuals without affordable coverage); or

(ii)

section 5000A(e)(5) of such title (relating to individuals with hardships).

(3)

Restriction to individual market

(f)

Child-only plans

(g)

Payments to Federally-qualified health centers

(Pub. L. 111–148, title I, § 1302, title X, § 10104(b), Mar. 23, 2010, 124 Stat. 163, 896; Pub. L. 113–93, title II, § 213(a), Apr. 1, 2014, 128 Stat. 1047.)

cite as: 42 USC 18022