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
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.
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