10 New Requirements for Health Plans

by Julie Seiner  

As of 1/1/14

Individual and small business health plans must offer a comprehensive benefit package that includes:

  1. Emergency Services
  2. Hospitalizations
  3. Vision and dental care for children
  4. Maternity care
  5. Mental health and substance abuse treatment
  6. Outpatient, or ambulatory care
  7. Pediatric care
  8. Preventative care
  9. Rehabilitative and habilitation services
  10. Laboratory services

Non-grandfathered plans also will have new requirements:

  1. New insured plan non-discrimination rules – fully insured plans will be prohibited from favoring highly compensated employees
  2. Minimum design requirements – Plans must cover essential health benefits and deductible limits.  For 2014 this requirement applies only to small employers
  3. Appeals process standards – Employees have a right to appeal their health insurance plan decisions. 
  4. Preventative care cost sharing requirements – There is no cost sharing (co-pays or co-insurance) for immunizations or preventative care
  5. Emergency services prior authorization – employees may seek emergency care at a hospital outside the plans network without prior approval from the health plan
  6. Emergency service out of network cost sharing – health plans may not require higher co-payments or co-insurance for out-of-network emergency room services
  7. Participants choice – Plan participants may select as a primary care physician a pediatrician or gynecologist without getting a referral from another doctor.

Grandfathered plans are defined as: a health insurance policy that was in place before the Affordable Care Act (ACA) was signed on March 23, 2010.  Grandfathered plans are not required to comply with the new requirements until they’ve made certain changes that cause them to lose their grandfathered status.


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One thought on “10 New Requirements for Health Plans

  1. Helen Adamopoulos (@BHR_Adamop) August 15, 2013 at 3:29 pm Reply

    Very informative post. I just covered a report on the essential benefits mandate, if you’re interested: http://bit.ly/14O9Lam. What do you think of the findings?

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