Section 4320-D - Comprehensive health coverageNotwithstanding any other requirements of this Title, a carrier offering a health plan in this State shall, at a minimum, provide coverage that incorporates an essential health benefits package consistent with the requirements of this section. [2019, c. 5, Pt. B, §1(AMD).]
1.Essential health benefits package; definition. As used in this section, "essential health benefits package" means, with respect to any health plan, coverage that: A. Provides for the essential health benefits in accordance with subsection 2; [2019, c. 5, Pt. B, §1(NEW).]B. Limits cost sharing for coverage in accordance with subsection 3; and [2019, c. 5, Pt. B, §1(NEW).]C. Provides for levels of coverage in accordance with subsection 4. [2019, c. 5, Pt. B, §1(NEW).] [2019, c. 5, Pt. B, §1(NEW).]
2.Substantially similar to federal Affordable Care Act; required categories. With respect to any individual or small group health plan offered on or after January 1, 2020, a carrier shall provide essential health benefits that are substantially similar to that of the essential health benefits required in this State for a health plan subject to the federal Affordable Care Act as of January 1, 2019. Essential health benefits required for a health plan must include at least the following general categories and the items and services covered within the categories: A. Ambulatory patient services; [2019, c. 5, Pt. B, §1(NEW).]B. Emergency services; [2019, c. 5, Pt. B, §1(NEW).]C. Hospitalization; [2019, c. 5, Pt. B, §1(NEW).]D. Maternity and newborn care; [2019, c. 5, Pt. B, §1(NEW).]E. Mental health and substance use disorder services, including behavioral health treatment; [2019, c. 5, Pt. B, §1(NEW).]F. Prescription drugs; [2019, c. 5, Pt. B, §1(NEW).]G. Rehabilitative and habilitative services and devices; [2019, c. 5, Pt. B, §1(NEW).]H. Laboratory services; [2019, c. 5, Pt. B, §1(NEW).]I. Preventive and wellness services and chronic disease management; and [2019, c. 5, Pt. B, §1(NEW).]J. Pediatric services, including oral and vision care, to the extent required by the federal Affordable Care Act as of January 1, 2019. [2019, c. 5, Pt. B, §1(NEW).] [2019, c. 5, Pt. B, §1(NEW).]
3.Cost-sharing limitations. With respect to any health plan offered on or after the effective date of this subsection, a carrier shall limit cost sharing on an annual basis in a manner that is consistent with the annual limits established for a health plan subject to the federal Affordable Care Act as of January 1, 2019 and as adjusted by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services, or, if the Centers for Medicare and Medicaid Services does not establish annual limits on cost sharing, the superintendent shall adopt rules establishing annual limits on cost sharing under this subsection that are calculated in substantially the same manner as the Centers for Medicare and Medicaid Services calculated the annual limit in the most recent year it calculated the annual limit. [2019, c. 5, Pt. B, §1(NEW).]
4.Levels of coverage. Carriers shall offer coverage at levels that are substantially similar to the levels of coverage required for health plans subject to the federal Affordable Care Act as of January 1, 2019. The superintendent may adopt rules defining such levels of coverage. Rules adopted pursuant to this subsection are routine technical rules as defined in Title 5, chapter 375, subchapter 2-A. [2019, c. 5, Pt. B, §1(NEW).]
5.Rule of construction. This section may not be construed to prohibit a health plan from providing benefits in excess of the essential health benefits described in this section. [2019, c. 5, Pt. B, §1(NEW).]
Amended by 2019, c. 5,§ B-1, eff. 3/19/2019.Added by 2011, c. 364,§ 34, eff. 9/28/2011.