Blue Access for Employers

Essential Health Benefits Coverage and Cost-Sharing Rules

Starting in 2014, non-grandfathered small group health plans must cover basic health services, called essential health benefits (EHBs), such as:

  • Servicios para pacientes ambulatorios
  • Hospitalización
  • Cuidados de maternidad y neonatales
  • Mental health and substance abuse disorder services, including behavioral health treatment
  • Rehabilitative and habilitative services and devices
  • Medicamentos con receta
  • Servicios de emergencia
  • Servicios de laboratorio
  • Preventive and wellness services and chronic disease management
  • Servicios pediátricos, que incluyen atención odontológica y para el cuidado de la vista
  • Servicios para pacientes ambulatorios
  • Medicamentos con receta
  • Servicios de emergencia
  • Rehabilitative and habilitative services and devices
  • Hospitalización
  • Servicios de laboratorio
  • Cuidados de maternidad y neonatales
  • Preventive and wellness services and chronic disease management
  • Mental health and substance abuse disorder services, including behavioral health treatment
  • Servicios pediátricos, que incluyen atención odontológica y para el cuidado de la vista

Grandfathered group health plans and large group health plans don't have to cover EHBs. However, if they choose to, they can't set annual or lifetime dollar limits.

If you get preventive care services from a doctor who’s on your insurance plan’s network,
you may not have to pay out-
of-pocket costs for your visit.


Cost-Sharing Rules

Non-grandfathered group health plans covering EHBs must also follow cost-sharing rules. Both small group and large group plans must limit annual out-of-pocket member expenses for in-network EHBs.

 

 

 






Since this is an overview, detailed information on this
topic — and more — is available.