Blue Cross and Blue Shield of Illinois

 

 

May 31, 2013

Legislative Update
Updated Essential Health Benefits (EHBs) Cost-Sharing Fast Facts
We previously published this article with CMS estimated 2014 out-of-pocket (OOP) limits for in-network EHBs. This article has been updated with the final 2014 OOP limits for in-network member EHB expenses released by the IRS in early May.

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, here are 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.  
  • 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 (see Question 8).
  • 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.
  • 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.  
  • FAQs about EHB out-of-pocket limits provide details about how the safe harbor works and other important questions (see Question 8).

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

This information does not constitute legal or tax advice and it may be subject to change. Please consult your summary plan description (SPD)/benefit booklet for the specific terms and conditions of your coverage.

 
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