Blue Cross and Blue Shield of Illinois

 

 

May 3, 2013

Legislative Update
Essential Health Benefits Cost-Sharing Fast Facts

The flurry of information about the essential health benefits’ (EHBs) deductible cap, out-of-pocket limits, and safe harbor for carve outs has many people scratching their heads. If you’re one of them, Blue Cross and Blue Shield of Illinois (BCBSIL) offers some fast facts and resources to help you keep up with it all.

Large, self-insured and grandfathered health plans don’t have to cover EHBs in 2014. However, if they cover EHBs …

  • These plans must meet certain EHB cost-sharing requirements (see chart below).  
  • All plans must eliminate annual dollar limits on EHBs for their 2014 plan year.
  • All plans must have already eliminated lifetime dollar limits.
  • Non-grandfathered plans must cap member out-of-pocket expenses for EHBs (in-network). There are exceptions under a safe harbor
  • Grandfathered plans are not required to cap out-of-pocket expenses for EHBs. 

Non-grandfathered fully insured small group health plans and non-grandfathered individual plans must cover EHBs in 2014.* And …

  • These plans must meet certain EHB cost-sharing requirements (see chart below).
  • Most of these plans must eliminate annual dollar limits on EHBs for their 2014 plan year.
  • All plans must have already eliminated lifetime dollar limits.
  • These plans must cap member out-of-pocket expenses for EHBs (in-network).
  • Non-grandfathered insured small group plans must cap deductibles for EHBs in 2014 at $2,000 for individual coverage and $4,000 for family coverage. The deductible cap can be exceeded if reasonably necessary to ensure the benefit plan hits a “metallic level” (actuarial value threshold).

All plan types can use these resources to help navigate the essential health benefits cost-sharing landscape: 

  • The EHB Cost-Sharing Requirements Recap provides a snapshot of these requirements based on a plan’s grandfathered status (see chart below)
  • Frequently Asked Questions (FAQs) about EHB out-of-pocket limits provide details about how the safe harbor works and other important questions.

*May be subject to your health plan’s anniversary date or plan year.

EHB Cost-Sharing Requirements Recap

Requirements

Details

Who must comply

No lifetime dollar  limits1on EHBs

  • Now and in the future
  • Includes in-network and out-of-network covered expenses
  • Grandfathered
  • Non-grandfathered
  • All group and individual plans

No annual dollar limits1 on  EHBs

  • Now and in the future
  • Must cover EHBs without annual dollar limits
  • Begins on group plan 2014 renewal date
  • Includes in-network and out-of-network covered expenses
  • Restricted annual dollar limits allowed through plan year Dec. 31, 2013 
  • Grandfathered
  • Non-grandfathered
  • All group and most individual plans

Restricted annual  dollar limits1 on EHBs

  • Must provide at least $2M in coverage for EHBs
  • Includes in-network and out-of-network covered expenses
  • BCBSIL has already removed annual dollar limits for group plans except for ASO/self-funded groups who have opted to set restricted annual dollar limits
  • Grandfathered
  • Non-grandfathered
  • All group  and most individual plans

Must cap member out-of-pocket expenses for EHBs

  • Begins on group plan 2014 renewal date
  • $6,400 individual/$12,800 family is the current CMS* estimated limit for 2014
  • There are exceptions under a safe harbor
  • Includes EHB expenses from in-network providers
  • Non-grandfathered
  • All group sizes and individual plans

Deductible cap for EHBs

  • Begins on group plan 2014 renewal date
  • $2,000 individual/$4,000 family
  • Includes EHB expenses from in-network providers
  • Non-grandfathered fully insured small group only for 2014
1Groups can set visit and frequency limits on some EHBs
*Centers for Medicare & Medicaid Services (CMS)

This information does not constitute legal advice and it may be subject to change. Members should consult their benefit booklet for the specific terms and conditions of their coverage.

Need more information? Review these FAQs about Essential Health Benefits out-of-pocket limits.

 

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association.