Commissioner Approves Emergency Regs for Essential Health Benefits

Insurance Commissioner Dave Jones approved an emergency regulation requiring health insurers to cover all essential health benefits for new policies in effect after January 1, 2014. The Affordable Care Act requires non-grandfathered health insurance policies in the individual and small group markets to provide coverage for a comprehensive package of healthcare benefits, known as “essential health benefits.” This applies to plans inside and outside of the health benefit exchange.

Jones said, “Our essential health benefits emergency regulation ensures all Californians purchasing individual or small group health insurance policies will have coverage for a comprehensive set of health benefits when they need medical care. In the past, some policies have included very limited or no coverage for important healthcare services. Starting in January all the new health insurance policies will cover 10 broad categories of essential benefits that will meet most healthcare needs. Issuance of the emergency regulation is a critical step in the implementation of the Affordable Care Act, because it provides the legal authority for the department to implement the essential health benefits requirement as we review new health insurance policies sold, including those in the Exchange.”

The Following 10 categories of benefits make up the essential health benefits coverage:

1. Ambulatory patient services
2. Emergency services
3. Maternity and newborn care
4. Prescription drugs
5. Hospitalization
6. Laboratory services
7. Pediatric services, including oral and vision care
8. Rehabilitative and habilitative services and devices
9. Preventive and wellness services and chronic disease management
10. Mental health and substance use disorder services, including behavioral health treatment.

Last Updated 09/16/2020

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