§18022 — Title 42 The Public Health and Welfare | U.S. Code

Summary

Health plans must provide an essential health benefits package. That package must cover the benefit types the Secretary of Health and Human Services defines, limit how much people pay out of pocket, and fit one of four “metal” levels of coverage. The benefit types include basic categories such as doctor visits, emergency care, hospital stays, maternity and newborn care, mental health and substance use treatment, prescription drugs, rehab services and devices, lab work, preventive care and chronic disease care, and pediatric services including dental and vision. The Secretary must set the details after getting public comment, a Labor survey of typical employer plans, and a certification from the Chief Actuary. The Secretary must review and update the list over time and report to Congress about access, evidence changes, and cost effects. Cost-sharing limits follow dollar caps set for 2014 under section 223(c)(2)(A)(ii) of Title 26 for self-only and family coverage. For plan years after 2014 the self-only cap rises each year by the “premium adjustment percentage” (based on changes in average per-person premiums since 2013), and the family cap is twice the self-only cap. “Cost-sharing” means deductibles, copays, coinsurance, and similar charges, not premiums or balance billing. Plans must treat emergency services without prior authorization and must charge the same copay/coinsurance for out-of-network emergency care as in-network care. Plans may offer more than the required benefits. Special limited plans may be sold only to people under 30 or those exempt from the individual mandate; those plans have delayed full benefits until the enrollee has reached the annual cost-sharing limit and must still cover at least three primary care visits. Exchanges must also offer versions of plans limited to enrollees under 21. If a federally qualified health center provides a covered service, the plan must pay at least the Medicaid payment rate specified in law.

Title 42, §18022

The Public Health and Welfare — Source: USLM XML via OLRC

(a)In this title,11 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)(1)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)(A)The Secretary shall ensure that the scope of the essential health benefits under paragraph (1) is equal to the scope of benefits provided under a typical employer plan, as determined by the Secretary. To inform this determination, the Secretary of Labor shall conduct a survey of employer-sponsored coverage to determine the benefits typically covered by employers, including multiemployer plans, and provide a report on such survey to the Secretary.

(B)In defining the essential health benefits described in paragraph (1), and in revising the benefits under paragraph (4)(H), the Secretary shall submit a report to the appropriate committees of Congress containing a certification from the Chief Actuary of the Centers for Medicare & Medicaid Services that such essential health benefits meet the limitation described in paragraph (2).

(3)In defining the essential health benefits described in paragraph (1), and in revising the benefits under paragraph (4)(H), the Secretary shall provide notice and an opportunity for public comment.

(4)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,22 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) 33 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 44 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)Nothing in this title 1 shall be construed to prohibit a health plan from providing benefits in excess of the essential health benefits described in this subsection.

(c)(1)(A)The cost-sharing incurred under a health plan with respect to self-only coverage or coverage other than self-only coverage for a plan year beginning in 2014 shall not exceed the dollar amounts in effect under section 223(c)(2)(A)(ii) of title 26 for self-only and family coverage, respectively, for taxable years beginning in 2014.

(B)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).

(2)

(3)In this title

(A)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)Such term does not include premiums, balance billing amounts for non-network providers, or spending for non-covered services.

(4)For purposes of paragraph (1)(B)(i), the premium adjustment percentage for any calendar year is the percentage (if any) by which the average per capita premium for health insurance coverage in the United States for the preceding calendar year (as estimated by the Secretary no later than October 1 of such preceding calendar year) exceeds such average per capita premium for 2013 (as determined by the Secretary).

(d)(1)The levels of coverage described in this subsection are as follows:

(A)A plan in the bronze level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 60 percent of the full actuarial value of the benefits provided under the plan.

(B)A plan in the silver level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 70 percent of the full actuarial value of the benefits provided under the plan.

(C)A plan in the gold level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 80 percent of the full actuarial value of the benefits provided under the plan.

(D)A plan in the platinum level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 90 percent of the full actuarial value of the benefits provided under the plan.

(2)(A)Under regulations issued by the Secretary, the level of coverage of a plan shall be determined on the basis that the essential health benefits described in subsection (b) shall be provided to a standard population (and without regard to the population the plan may actually provide benefits to).

(B)The Secretary shall issue regulations under which employer contributions to a health savings account (within the meaning of section 223 of title 26) may be taken into account in determining the level of coverage for a plan of the employer.

(C)In determining under this title,1 the Public Health Service Act [42 U.S.C. 201 et seq.], or title 26 the percentage of the total allowed costs of benefits provided under a group health plan or health insurance coverage that are provided by such plan or coverage, the rules contained in the regulations under this paragraph shall apply.

(3)The Secretary shall develop guidelines to provide for a de minimis variation in the actuarial valuations used in determining the level of coverage of a plan to account for differences in actuarial estimates.

(4)In this title,1 any reference to a bronze, silver, gold, or platinum plan shall be treated as a reference to a qualified health plan providing a bronze, silver, gold, or platinum level of coverage, as the case may be.

(e)(1)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)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)If a health insurance issuer offers a health plan described in this subsection, the issuer may only offer the plan in the individual market.

(f)If a qualified health plan is offered through the Exchange in any level of coverage specified under subsection (d), the issuer shall also offer that plan through the Exchange in that level as a plan in which the only enrollees are individuals who, as of the beginning of a plan year, have not attained the age of 21, and such plan shall be treated as a qualified health plan.

(g)If any item or service covered by a qualified health plan is provided by a Federally-qualified health center (as defined in section 1396d(l)(2)(B) of this title) to an enrollee of the plan, the offeror of the plan shall pay to the center for the item or service an amount that is not less than the amount of payment that would have been paid to the center under section 1396a(bb) of this title) for such item or service.

Notes & Related Subsidiaries

Editorial Notes

References in Text

This title, referred to in subsecs. (a), (b)(5), (d)(2)(C), (4), and (e)(2)(B), is title I of Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 130, which enacted this chapter and enacted, amended, and transferred numerous other sections and notes in the Code. For complete classification of title I to the Code, see Tables. The Public Health Service Act, referred to in subsec. (d)(2)(C), is act July 1, 1944, ch. 373, 58 Stat. 682, which is classified generally to chapter 6A (§ 201 et seq.) of this title. For complete classification of this Act to the Code, see

Short Title

note set out under section 201 of this title and Tables. section 2713, referred to in subsec. (e)(1)(B)(i), probably means section 2713 of act July 1, 1944, which is classified to section 300gg–13 of this title.

Amendments

2014—Subsec. (c)(2). Pub. L. 113–93, § 213(a)(1), struck out par. (2) which related to annual limitation on deductibles for employer-sponsored plans. Subsec. (c)(4). Pub. L. 113–93, § 213(a)(2), which directed amendment of par. (4)(A) by substituting “paragraph (1)(B)(i)” for “paragraphs (1)(B)(i) and (2)(B)(i)”, was executed by making the substitution in par. (4) to reflect the probable intent of Congress. 2010—Subsec. (d)(2)(B). Pub. L. 111–148, § 10104(b)(1), substituted “shall issue” for “may issue”. Subsec. (g). Pub. L. 111–148, § 10104(b)(2), added subsec. (g).

Statutory Notes and Related Subsidiaries

Effective Date

of 2014 AmendmentAmendment by Pub. L. 113–93 effective as if included in the enactment of Pub. L. 111–148, see section 213(c) of Pub. L. 113–93, set out as a note under section 300gg–6 of this title.

§18022 Essential Health Benefits Requirements