Essential Health Benefits

On December 16, 2011, DHH issued a bulletin outlining proposed policies that will give states more flexibility and freedom to implement the Affordable Care Act.

Essential health benefits must include items and services within at least the following 10 categories:



Under the department’s intended approach announced today, states would have the flexibility to select a benchmark plan that reflects the scope of services offered by a “typical employer plan.” This approach would give states the flexibility to select a plan that would best meet the needs of their citizens.


It is important to note that the Affordable Care Act distinguishes between a health plan’s covered services, and the plan’s cost-sharing features, such as deductibles, copayment, and coinsurance. The cost-sharing features will be addressed in separate rules and will determine the actuarial value of the plan, expressed as a “metal level” as specified in statute:

bronze at 60% actuarial value,

silver at 70% actuarial value,

gold at 80% actuarial value, and

platinum at 90% actuarial value.


Qualified Health Plan


Under the Affordable Care Act, starting in 2014, an insurance plan that is certified by an Exchange, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayment, and out-of-pocket maximum amounts), and meets other requirements. A qualified health plan will have a certification by each Exchange in which it is sold.


Source:  Healthcare.gov                                   By William F. Schaake, CIC, CRM  © 2012