The Patient Protection and Affordable Care Act provisions that took effect Jan. 1, 2014, require health care coverage for individual- and small-group markets on one of four levels—referred to as an essential health benefits package—bronze, silver, gold and platinum.
Nongrandfathered health insurance in the small group for this purpose means employers with up to 100 workers.
Metal Plans
The different levels refer to the percentage of health care costs paid by the health plan: bronze, 60 percent; silver, 70 percent; gold, 80 percent; and platinum, 90 percent. Typically, the higher the percentage of health plan coverage, the higher the premiums, deductibles and co-payments.
Metal plans allow apples-to-apples comparison of health plans in the individual and small markets.
“The metal-levels requirement doesn’t apply to the large group market, so group health plans sponsored by larger employers won’t necessarily follow the bronze, silver, gold and platinum framework,” noted Stephanie Vasconcellos, an attorney at Neal, Gerber & Eisenberg in Chicago. But “to the extent that a health plan does follow the metal framework, though, it might be useful for a group health plan to provide the metal level in communications about its plan,” such as during open enrollment.
Essential Health Benefits
All the metal plans cover 10 required services.
Paul Hamburger, an attorney at Proskauer in Washington, D.C., explained that the health care reform law lists 10 categories of essential health benefits. “Insured plans in the small and individual group markets must offer coverage under each category of essential health benefits,” he said.
The 10 categories are:
- Ambulatory patient services.
- Emergency services.
- Hospitalization.
- Maternity and newborn care.
- Mental-health and substance-use-disorder services, including behavioral-health treatment.
- Prescription drugs.
- Rehabilitative and habilitative services and devices.
- Laboratory services.
- Preventive and wellness services and chronic disease management.
- Pediatric services, including oral and vision care.
Minimum essential coverage, by contrast, is coverage “that an individual must obtain in order to avoid paying a penalty for a lack of coverage,” Hamburger said.
Allen Smith, J.D., is the manager of workplace content for SHRM. Follow him@SHRMlegaleditor.
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