Amended by section 10104 of the Manager’s Amendment. Defines the essential health benefits (EHB) package as coverage providing HHS-defined EHBs, limiting cost sharing and having a certain actuarial value (AV) as denoted by certain metallic categories. Provides for HHS-defined EHBs within at least 10 general, statutory categories. Specifies that such EHBs should be equal in scope to the benefits provided under a typical employer plan; requires the Department of Labor to conduct a survey of employer-sponsored coverage to inform this determination and provides a list of elements for HHS’s consideration in establishing EHBs.
Creates annual cost-sharing limits beginning in 2014 to Health Savings Account dollar amounts for self-only and family coverage for taxable years beginning in 2014. Limits deductibles under small group plans to $2,000 for individuals and $4,000 for any other plan (which can be increased by available flexible spending account funds). Provides for indexing mechanisms for both of these provisions.
Delineates four levels of coverage associated with specified AVs: bronze (60 percent); silver (70 percent); gold (80 percent); and platinum (90 percent). HHS will develop guidelines allowing for de minimis variation, and under HHS regulations, the plan’s level of coverage will be determined based on EHBs provided to a standard population.
Creates catastrophic (high-deductible) plans in the individual market available to individuals under age 30 who are exempt from the personal responsibility requirement because of affordability or hardship reasons; these plans must cover EHBs and at least three primary care visits. Requires that if a Qualified Health Plan (QHP) is offered through the Exchange in any metallic tier, the issuer must offer that plan through the Exchange in that tier as a child-only QHP.