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” 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.
Employee benefit plans must have an SPD unless one of the below exceptions applies:
- Government and church plans are exempt from Title 1 of ERISA.
- Cafeteria plans are exempt from the SPD requirement
- Employer provided day care centers are exempt from the SPD requirement
- 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.
*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.
