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Essential Benefits

The Department of Health and Human Services has released proposed rules regarding the “essential benefits” provision of the health care reform law. The new rules note that starting in 2014, nongrandfathered health plans in the individual and small-group markets must provide coverage for the 10 “essential” services. They are:


  • Ambulatory/outpatient


  • Emergency


  • Hospitalization


  • Maternity and newborn care


  • Mental health and substance use


  • Prescription drugs


  • Rehabilitative and habilitative services and devices – e.g., speech, physical and occupational therapy


  • Laboratory services


  • Preventive and wellness services and chronic disease management


  • Pediatric services, including pediatric dental and vision care


The rules also call for plans to provide coverage that meets the “metal” standards (an actuarial value of 60, 70, 80 or 90 percent; actuarial value means the percentage of allowed costs the plan is expected to pay for a standard population).