Essential Health Benefits Defined • July, 2010

Healthcare reform includes unlimited coverage for some benefits…. While the final list is still up in the air, we can at least provide a preliminary look under the covers.

And did I say unlimited? Well, that won’t be required until late in 2013. But they will up the minimums between now and then.

Annual Limits
The government is allowing plans to phase in unlimited coverage of essential health benefits. They are calling these “Restricted Annual Limits”.

The limits allowed per individual annually, per essential benefit, are:


A Funny Thing Happened on the Way to Unlimited And just when you thought unlimited meant unlimited, well… the regulations again. They state that a plan cannot place a dollar limit on essential benefits.

The legal beagles out there are noting that this means the plan can still place day or visit limits on these benefits. Unless this loophole is plugged by the Feds, be prepared to see plans adding day and visit limits on all essential health benefits.

Essential Health Benefits
The list of benefits in the act is outlined below. However, this list could be expanded in the future.

  • 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
  • chronic disease management
  • pediatric services, including oral and vision care

No Coverage….No Maximum
One final word on these regulations. If your plan does not include an essential health service, it does not need to add that specific coverage until 2014.

This article is provided for informational purposes only. Please contact your attorney and/or accountant to determine if this information may affect your business. © 2015 GHB Insurance

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