To build on last week’s article, this week’s Focus article discusses the types of insurance coverage that will be available in North Carolina’s Exchange.

Section 1301 of the Patient Protection and Affordable Care Act (PPACA) only allows “qualified health benefit plans” (QHPs) to be sold on the Exchange.  A QHP is a health plan that: (1) contains a specific level of coverage that meets the designation of an “essential health benefits package;” (2) is offered by a licensed health insurer; and (3) is certified as eligible to be offered on the Exchange.  The essential health benefits package is the most important component of a QHP and deserves further attention.

What Does an Essential Health Benefits Package Include?

Effective in 2014, an essential package must include specific categories of benefits, provide minimum levels of coverage, and meet certain cost-sharing requirements.  See PPACA, sec. 1302.  The categories of benefits must include:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder treatment, including behavioral health treatment
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

The Act empowers the U.S. Secretary of Health & Human Services to further define the essential package, while maintaining a balance among the essential benefits, making non-discriminatory design decisions, and considering diverse health needs.  Of course, insurers may construct their plans to provide extended coverage or additional benefits beyond the essential health benefits package.

Levels of Coverage

Remember that plans that offer an essential benefits package and that meet the additional criteria of a QHP may still be different.  To help consumers, the Exchange will categorize the QHPs based on each plan’s level of coverage using the following system:

Bronze Level:  A plan designed to provide benefits that are actuarially equivalent to 60% of the actuarial value of the benefits provided.

Silver Level:  A plan designed to provide benefits that are actuarially equivalent 70% of the actuarial value of the benefits provided.

Gold Level: A plan designed to provide benefits that are actuarially equivalent 80% of the actuarial value of the benefits provided.

Platinum Level: A plan designed to provide benefits that are actuarially equivalent 90% of the actuarial value of the benefits provided.

Many other details about North Carolina’s Health Benefit Exchange must still be decided at the federal and state level.  NCMS will bring you more on Exchanges as additional information becomes available.

Editor’s Note: At the direction of the NCMS Board of Directors, your NCMS staff is examining and reporting on specific provisions contained in the Patient Protection and Affordable Care Act.  The series is archived on the NCMS website, www.ncmedsoc.org and is also available as a podcast (mp3).