Since the beginning of the Affordable Care Act, Florida Blue has been committed to complying with the law and actively working to bring it to life. That includes making sure we have the essential health benefits and other features in our plans, so our products can be sold on the health insurance Marketplace, sometimes called the “exchange.”
Here’s a look at what the ACA requires and what our plans must include, starting Jan. 1, 2014:
- Qualified Health Plan
- Essential Health Benefits
- Actuarial Value and Metal Levels
- Catastrophic Plans
- Rating Criteria
Qualified Health Plan
A Qualified Health Plan (QHP) is a health insurance plan that is certified by a marketplace. Some requirements of the QHPs are:
- Offered by licensed health insurers;
- Provide essential health benefits (EHBs)
- Follow established limits on cost-sharing (like deductibles, copayments and out-of-pocket maximum amounts); and
- Include essential community providers in our networks who serve low-income, underserved communities.
Essential Health Benefits
All insurers will have to cover essential health benefits (EHBs) in all individual and small-group health plans created for the Marketplace, with no annual or lifetime limits on the amount the insurer will pay. These EHBs are defined in 10 categories:
- Ambulatory patient services, including office visits, specialist visits, facility visits, etc.
- Emergency services;
- Maternity and newborn care;
- Mental health, behavioral health and substance abuse treatment;
- Prescription drugs;
- Rehabilitative and habilitative services. Habilitative services are a new category of treatment and will be managed just like rehab services.
- Laboratory services;
- Preventive and wellness services and chronic disease management; and
- Pediatric services, including coverage for vision and oral care (including orthodontia) for children under the age of 18.
Some existing health insurance products already include all of these services. But under the ACA, all insurance products offered on the Marketplace will be required to cover these benefits.
Actuarial Value and Metal Levels
Actuarial value (AV) is calculated as the percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an AV of 70 percent, on average, a consumer would be responsible for 30 percent of the costs of all covered benefits.
Beginning in 2014, new health plans created for the Marketplace in the individual and small group markets must meet certain AVs, or metal levels:
These metal levels will allow consumers to compare plans with similar levels of coverage and consider factors such as premium amounts and provider participation to make informed decisions on which health plan best fits their needs.
Catastrophic plans are available to individuals under the age of 30 or those who have a demonstrated financial hardship that the Internal Revenue Service has validated. While catastrophic plans include coverage for EHBs and three primary care visits, consumers must meet an annual deductible of $6,350 before coverage begins. In addition, catastrophic plans are not eligible for premium tax credits.
New rating rules for non-grandfathered individual and small group health plans take effect in 2014:
- People can’t be turned down for pre-existing conditions, nor will anyone have to provide their medical history for the insurer to determine their rate.
- Coverage is guaranteed to everyone who applies and the factors that will be used to determine premiums will be limited to:
- Children ages 0 – 20 will be charged the same rate, adults 21 – 63 are subject to the 3:1 band, and adults 64+ will be charged the same rate.
- Family composition (the sum of the rate for each person to be covered, up to three children under age 21 to account for larger families);
- Geography (zip code where the applicants live); and
- Tobacco use (rates can be up to 50-percent higher for tobacco users).
- Once someone is enrolled in a plan, his or her coverage cannot be canceled except in situations such as fraud, material misrepresentation, or failure to pay premiums.
Florida Blue is here to help you make sense of health care and health care reform. Check our blog weekly for more health care reform articles. You can also visit us in person at one of our Florida Blue Centers, go online or call 1-800-633-6808.
This information is for illustrative purposes only and is being provided to help increase understanding of the impacts of some of the provisions of the Affordable Care Act (ACA). It does not attempt to cover all of the law’s provisions and is not intended as tax or legal advice.