Milestone: Determine how health plan benefit design in the Exchange will meet federal standards for essential benefits and tiers
Plans offered by state Exchanges must meet federal standards for covered services and cost-sharing. The choices states make in order to meet or exceed the standards will affect access, utilization, and outcomes.
*Full name: Determine how health plan benefit design within the Exchange will meet federal standards for essential health benefits and the defined benefit tiers.
*Relevance to the ACA:
The ACA establishes benefit tiers and the requirement for essential health benefits. Relevant sections include:
§1302 - Charges the Secretary of HHS with defining essential health benefits that include inpatient and outpatient care, emergency care, rehabilitation services, mental health treatment, preventive and maternity care, laboratory services, pediatric care and prescription drugs. The Secretary must take into account certain special populations, including women, children, persons with disabilities, and others when defining benefits. Also defines levels of coverage: bronze, silver, gold and platinum, based on the actuarial value of the essential benefits and limits on cost-sharing and deductibles. The Secretary must ensure that the scope of essential benefits is equal to a typical employer plan.
§1311 - States may require additional benefits for plans that offer coverage through the Exchange, but they must assume the cost of those benefits.less