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The Affordable Care Act (ACA) requires that all health insurance plans sold on state exchanges beginning Jan. 1, 2014 cover ten essential benefits:
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease management
Pediatric services, including oral and vision care
However, the specifics of what will be included in each of the categories have been left to individual states. Each state will choose an existing health plan to use as a model:
One of the three largest small-group plans in the state
One of the three largest state employee health plans
One of the three largest federal employee health plan options
The largest HMO plan offered in the state’s commercial market
In addition to addressing what will be covered, the ACA also broadly outlined the level of benefits – how health care costs will be split between health plans and consumers.
General percentage by level paid by consumer
(through deductibles, copays and coinsurance)
Bronze Level – 40%
Silver Level – 30%
Gold Level – 20%
Platinum Level – 10%
