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Statutory Text

SEC. 1302 [42 U.S.C. 18022]. ESSENTIAL HEALTH BENEFITS REQUIREMENTS.
(a) ESSENTIAL HEALTH BENEFITS PACKAGE.—In this title, the
term ‘‘essential health benefits package’’ means, with respect to
any health plan, coverage that—
(1) provides for the essential health benefits defined by the
Secretary under subsection (b);
(2) limits cost-sharing for such coverage in accordance with
subsection (c); and
(3) subject to subsection (e), provides either the bronze, silver,
gold, or platinum level of coverage described in subsection
(d).
(b) ESSENTIAL HEALTH BENEFITS.— (1) IN GENERAL.—Subject to paragraph (2), the Secretary
shall define the essential health benefits, except that such benefits
shall include at least the following general categories and
the items and services covered within the categories:
(A) Ambulatory patient services.
(B) Emergency services.
(C) Hospitalization.
(D) Maternity and newborn care.
(E) Mental health and substance use disorder services,
including behavioral health treatment.
(F) Prescription drugs.
(G) Rehabilitative and habilitative services and devices.
(H) Laboratory services.
(I) Preventive and wellness services and chronic disease
management.
(J) Pediatric services, including oral and vision care.
(2) LIMITATION.—
(A) IN GENERAL.—The Secretary shall ensure that the
scope of the essential health benefits under paragraph (1)
is equal to the scope of benefits provided under a typical
employer plan, as determined by the Secretary. To inform
this determination, the Secretary of Labor shall conduct
survey of employer-sponsored coverage to determine the
benefits typically covered by employers, including multiemployer
plans, and provide a report on such survey to the
Secretary.
(B) CERTIFICATION.—In defining the essential health
benefits described in paragraph (1), and in revising the
benefits under paragraph (4)(H), the Secretary shall submit
a report to the appropriate committees of Congress
containing a certification from the Chief Actuary of the
Centers for Medicare & Medicaid Services that such essential
health benefits meet the limitation described in paragraph
(2).
(3) NOTICE AND HEARING.—In defining the essential health
benefits described in paragraph (1), and in revising the benefits
under paragraph (4)(H), the Secretary shall provide notice
and an opportunity for public comment.
(4) REQUIRED ELEMENTS FOR CONSIDERATION.—In defining
the essential health benefits under paragraph (1), the Secretary
shall—
(A) ensure that such essential health benefits reflect
an appropriate balance among the categories described in
such subsection, so that benefits are not unduly weighted
toward any category;
(B) not make coverage decisions, determine reimbursement
rates, establish incentive programs, or design benefits
in ways that discriminate against individuals because
of their age, disability, or expected length of life;
(C) take into account the health care needs of diverse
segments of the population, including women, children,
persons with disabilities, and other groups;
(D) ensure that health benefits established as essential
not be subject to denial to individuals against their
wishes on the basis of the individuals’ age or expected
length of life or of the individuals’ present or predicted disability,
degree of medical dependency, or quality of life;
(E) provide that a qualified health plan shall not be
treated as providing coverage for the essential health benefits
described in paragraph (1) unless the plan provides
that—
(i) coverage for emergency department services
will be provided without imposing any requirement
under the plan for prior authorization of services or
any limitation on coverage where the provider of services
does not have a contractual relationship with the
plan for the providing of services that is more restrictive
than the requirements or limitations that apply to
emergency department services received from providers
who do have such a contractual relationship
with the plan; and
(ii) if such services are provided out-of-network,
the cost-sharing requirement (expressed as a copayment
amount or coinsurance rate) is the same requirement
that would apply if such services were provided
in-network;
(F) provide that if a plan described in section
1311(b)(2)(B)(ii) (relating to stand-alone dental benefits
plans) is offered through an Exchange, another health plan
offered through such Exchange shall not fail to be treated
as a qualified health plan solely because the plan does not
offer coverage of benefits offered through the stand-alone
plan that are otherwise required under paragraph (1)(J);
and
(G) periodically review the essential health benefits
under paragraph (1), and provide a report to Congress and
the public that contains—
(i) an assessment of whether enrollees are facing
any difficulty accessing needed services for reasons of
coverage or cost;
(ii) an assessment of whether the essential health
benefits needs to be modified or updated to account for
changes in medical evidence or scientific advancement;
(iii) information on how the essential health benefits
will be modified to address any such gaps in access
or changes in the evidence base;
(iv) an assessment of the potential of additional or
expanded benefits to increase costs and the interactions
between the addition or expansion of benefits
and reductions in existing benefits to meet actuarial
limitations described in paragraph (2); and
(H) periodically update the essential health benefits
under paragraph (1) to address any gaps in access to coverage
or changes in the evidence base the Secretary identifies
in the review conducted under subparagraph (G).
(5) RULE OF CONSTRUCTION.—Nothing in this title shall be
construed to prohibit a health plan from providing benefits in
excess of the essential health benefits described in this subsection.

(c) REQUIREMENTS RELATING TO COST-SHARING.—
(1) ANNUAL LIMITATION ON COST-SHARING.—
(A) 2014.—The cost-sharing incurred under a health
plan with respect to self-only coverage or coverage other
than self-only coverage for a plan year beginning in 2014
shall not exceed the dollar amounts in effect under section
223(c)(2)(A)(ii) of the Internal Revenue Code of 1986 for
self-only and family coverage, respectively, for taxable
years beginning in 2014.
(B) 2015 AND LATER.—In the case of any plan year beginning
in a calendar year after 2014, the limitation under
this paragraph shall—
(i) in the case of self-only coverage, be equal to the
dollar amount under subparagraph (A) for self-only
coverage for plan years beginning in 2014, increased
by an amount equal to the product of that amount and
the premium adjustment percentage under paragraph
(4) for the calendar year; and
(ii) in the case of other coverage, twice the amount
in effect under clause (i).
If the amount of any increase under clause (i) is not a multiple
of $50, such increase shall be rounded to the next
lowest multiple of $50.
(2) ANNUAL LIMITATION ON DEDUCTIBLES FOR EMPLOYER- SPONSORED PLANS.— (A) IN GENERAL.—In the case of a health plan offered
in the small group market, the deductible under the plan
shall not exceed—
(i) $2,000 in the case of a plan covering a single
individual; and (ii) $4,000 in the case of any other plan.
The amounts under clauses (i) and (ii) may be increased by
the maximum amount of reimbursement which is reasonably
available to a participant under a flexible spending
arrangement described in section 106(c)(2) of the Internal
Revenue Code of 1986 (determined without regard to any
salary reduction arrangement).
(B) INDEXING OF LIMITS.—In the case of any plan year
beginning in a calendar year after 2014—
(i) the dollar amount under subparagraph (A)(i)
shall be increased by an amount equal to the product
of that amount and the premium adjustment percentage
under paragraph (4) for the calendar year; and
(ii) the dollar amount under subparagraph (A)(ii)
shall be increased to an amount equal to twice the
amount in effect under subparagraph (A)(i) for plan
years beginning in the calendar year, determined after
application of clause (i).
If the amount of any increase under clause (i) is not a multiple
of $50, such increase shall be rounded to the next
lowest multiple of $50.
(C) ACTUARIAL VALUE.—The limitation under this
paragraph shall be applied in such a manner so as to not
affect the actuarial value of any health plan, including a
plan in the bronze level.
(D) COORDINATION WITH PREVENTIVE LIMITS.—Nothing
in this paragraph shall be construed to allow a plan to
have a deductible under the plan apply to benefits described
in section 2713 of the Public Health Service Act.
(3) COST-SHARING.—In this title—
(A) IN GENERAL.—The term ‘‘cost-sharing’’ includes—
(i) deductibles, coinsurance, copayments, or similar
charges; and
(ii) any other expenditure required of an insured
individual which is a qualified medical expense (within
the meaning of section 223(d)(2) of the Internal
Revenue Code of 1986) with respect to essential health
benefits covered under the plan.
(B) EXCEPTIONS.—Such term does not include premiums,
balance billing amounts for non-network providers,
or spending for non-covered services.
(4) PREMIUM ADJUSTMENT PERCENTAGE.—For purposes of
paragraphs (1)(B)(i) and (2)(B)(i), the premium adjustment percentage
for any calendar year is the percentage (if any) by
which the average per capita premium for health insurance
coverage in the United States for the preceding calendar year
(as estimated by the Secretary no later than October 1 of such
preceding calendar year) exceeds such average per capita premium
for 2013 (as determined by the Secretary).
(d) LEVELS OF COVERAGE.— (1) LEVELS OF COVERAGE DEFINED.—The levels of coverage
described in this subsection are as follows:
(A) BRONZE LEVEL.—A plan in the bronze level shall
provide a level of coverage that is designed to provide benefits
that are actuarially equivalent to 60 percent of the
full actuarial value of the benefits provided under the
plan.
(B) SILVER LEVEL.—A plan in the silver level shall provide
a level of coverage that is designed to provide benefits
that are actuarially equivalent to 70 percent of the full actuarial
value of the benefits provided under the plan.
(C) GOLD LEVEL.—A plan in the gold level shall provide
a level of coverage that is designed to provide benefits
that are actuarially equivalent to 80 percent of the full actuarial
value of the benefits provided under the plan.
(D) PLATINUM LEVEL.—A plan in the platinum level
shall provide a level of coverage that is designed to provide
benefits that are actuarially equivalent to 90 percent of
the full actuarial value of the benefits provided under the
plan.
(2) ACTUARIAL VALUE.—
(A) IN GENERAL.—Under regulations issued by the Secretary,
the level of coverage of a plan shall be determined
on the basis that the essential health benefits described in
subsection (b) shall be provided to a standard population
(and without regard to the population the plan may actually
provide benefits to).
(B) EMPLOYER CONTRIBUTIONS.—øAs revised by section
10104(b)(1)¿ The Secretary shall issue regulations under
which employer contributions to a health savings account
(within the meaning of section 223 of the Internal Revenue
Code of 1986) may be taken into account in determining
the level of coverage for a plan of the employer.
(C) APPLICATION.—In determining under this title, the
Public Health Service Act, or the Internal Revenue Code
of 1986 the percentage of the total allowed costs of benefits
provided under a group health plan or health insurance
coverage that are provided by such plan or coverage, the
rules contained in the regulations under this paragraph
shall apply.
(3) ALLOWABLE VARIANCE.—The Secretary shall develop
guidelines to provide for a de minimis variation in the actuarial
valuations used in determining the level of coverage of a
plan to account for differences in actuarial estimates.
(4) PLAN REFERENCE.—In this title, any reference to a
bronze, silver, gold, or platinum plan shall be treated as a reference
to a qualified health plan providing a bronze, silver,
gold, or platinum level of coverage, as the case may be. (e) CATASTROPHIC PLAN.—
(1) IN GENERAL.—A health plan not providing a bronze, silver,
gold, or platinum level of coverage shall be treated as
meeting the requirements of subsection (d) with respect to any
plan year if—
(A) the only individuals who are eligible to enroll in
the plan are individuals described in paragraph (2); and
(B) the plan provides—
(i) except as provided in clause (ii), the essential
health benefits determined under subsection (b), except
that the plan provides no benefits for any plan
year until the individual has incurred cost-sharing expenses
in an amount equal to the annual limitation in
effect under subsection (c)(1) for the plan year (except
as provided for in section 2713); and
(ii) coverage for at least three primary care visits.
(2) INDIVIDUALS ELIGIBLE FOR ENROLLMENT.—An individual
is described in this paragraph for any plan year if the
individual—
(A) has not attained the age of 30 before the beginning
of the plan year; or
(B) has a certification in effect for any plan year under
this title that the individual is exempt from the requirement
under section 5000A of the Internal Revenue Code of
1986 by reason of—
(i) section 5000A(e)(1) of such Code (relating to individuals
without affordable coverage); or
(ii) section 5000A(e)(5) of such Code (relating to
individuals with hardships).
(3) RESTRICTION TO INDIVIDUAL MARKET.—If a health insurance
issuer offers a health plan described in this subsection,
the issuer may only offer the plan in the individual market.
(f) CHILD-ONLY PLANS.—If a qualified health plan is offered
through the Exchange in any level of coverage specified under subsection
(d), the issuer shall also offer that plan through the Exchange
in that level as a plan in which the only enrollees are individuals
who, as of the beginning of a plan year, have not attained
the age of 21, and such plan shall be treated as a qualified health
plan.
(g) PAYMENTS TO FEDERALLY-QUALIFIED HEALTH CENTERS.—
[As added by section 10104(b)(2)] If any item or service covered by
a qualified health plan is provided by a Federally-qualified health
center (as defined in section 1905(l)(2)(B) of the Social Security Act
(42 U.S.C. 1396d(l)(2)(B)) to an enrollee of the plan, the offeror of
the plan shall pay to the center for the item or service an amount
that is not less than the amount of payment that would have been
paid to the center under section 1902(bb) of such Act (42 U.S.C.
1396a(bb)) for such item or service.