The Affordable Health Care Act

The Affordable Care Act ensures health plans offered in the individual and small group markets, both inside and outside of the Health Insurance Marketplace, offer a comprehensive package of items and services, known as essential health benefits.
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The Ten Essential Health Benefits

  • Ambulatory Patient Services

    Care that you receive without being admitted to a hospital.

  • Outpatient Care

    Care that you receive without being admitted to a hospital.

  • Emergency Services

    Treatment in a hospital for in-patient care.

  • Maternity and Newborn Care

    Care before and after your baby is born.

  • Mental Health and Substance Abuse Disorder Services

    Includes behavioral health treatment.

  • Prescription Drugs

    Benefits for prescription drugs from the pharmacy.

  • Rehabilitative and Rehabilitation Services and Devices

    Services and devices to help you recover if you are injured, or have a disability or chronic condition.

  • Laboratory Services

    Your lab tests.

  • Preventive and Wellness Services and Chronic Disease Management

    Services to keep you healthy and care for managing a chronic disease.

  • Pediatric Services

    Includes vision and oral care.

More Health Care Reform Topics

Pediatric Services are one of the ten Essential Health Benefits (EHBs) that all non-grandfathered, fully insured small groups (fewer than 50 employees) are required to provide, with the start of plan years that begin on or after January 1, 2014. This is required regardless of whether there are any eligible employees or dependents for these services.

“Pediatric” is defined as under the age of 19.

Pediatric services include dental checkups and vision exams. Medical carriers are the 1st responsible party to include Pediatric Services in their plans. Medical plans offered in the small group market may automatically include pediatric benefits, and may require the group to provide an attestation form for the provision of pediatric benefits as a stand-alone plan, in order to remove the pediatric benefits from the medical plan.

*Some medical carriers will automatically include both Pediatric Dental and Vision in all medical plans. The Pediatric Dental component can be removed as there is a separate charge for these services. Some carriers require a Dental Attestation form to remove this benefit from the plan. The Dental Attestation Form will confirm that the group on behalf of their members have purchased and obtained the pediatric dental essential health benefit through another carrier. Agents will need to submit the attestation form to the managing agent to have the pediatric dental benefit removed from the plan. Pediatric Vision is built into the rates for all Blue Cross and Blue Care Network plans therefore this benefit cannot be removed from the plan even if the group has a stand-alone vision carrier.

Self-funded, grandfathered, and large group plans do not have to offer the pediatric dental benefit.

All employers with 2 or more employees that offer Group Welfare Benefits are required to provide a summary plan description (SPD) outlining in a clear and concise manner their benefits that are compliant with ERISA, PPACA and other laws. ERISA requires every employee benefit plan to have a summary plan description. The SPD is the primary vehicle for informing participants about their rights and benefits under their employee benefit plan.

Employee benefit plans must have an SPD unless one of the below exceptions applies:

  1. Government and church plans are exempt from Title 1 of ERISA.
  2. Cafeteria plans are exempt from the SPD requirement
  3. Employer provided day care centers are exempt from the SPD requirement
  4. An unfunded or insured welfare plan maintained by an Employer for the purpose of providing benefits to a select group of management or highly compensated employees would not need to provide the SPD.

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Under the law, insurance companies and group health plans must provide consumers with a concise document detailing, in plain language, simple and consistent information about health plan benefits and coverage. This summary of benefits and coverage (SBC) document will help consumers better understand the coverage they have and, for the first time, allowing them to easily compare different coverage options.

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The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. COBRA only applies to employers with 20 or more employees.

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Full time employees are those who worked on average 30 hours or more a week for more than 120 days in a year. Part time employees are those who worked on average less than 30 hours per week, but more than 120 days per year.

*Full time employees that work at least 30 hours per week in any month are counted as one full time employee. Part time employees are calculated by taking the hours worked by all part time employees in a week and dividing that amount by 30. This amount is added to the number of full time employees to determine an Employers “true” group size. Please click on the link for an FTE calculator this will allow you to determine your group size.

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