New Healthcare Law for 2014 Will Benefit Consumers (and Providers)

CMS announced it has passed a new rule aimed at providing states and insurers with more flexibility in implementing the Affordable Care Act.

Consumers will have a consistent way to compare and enroll in health coverage in the individual and small group markets.  This will make it easier for consumers to purchase insurance that will provide better quality, and expanded coverage and benefits. 

Medical Billing NewsKey Points are:

  • A core package of “Essential Health Benefits” has been developed that must include items and services within at least the following 10 categories:

1.       Ambulatory patient services

2.       Emergency services

3.       Hospitalization

4.       Maternity and newborn care

5.       Mental health and substance use disorder services, including behavioral health treatment

6.       Prescription drugs

7.       Rehabilitative and habilitative services and devices

8.       Laboratory services

9.       Preventive and wellness services and chronic disease management

10.   Pediatric services, including oral and vision care

Note:  Substance use disorder and behavioral health services have had a history of falling into the gap of coverage for millions of Americans.   The rule seeks to fix that gap in coverage by expanding coverage of these benefits in three distinct ways: 

o   By including mental health and substance use disorder benefits as Essential Health Benefits.

o   By applying federal parity protections to mental health and substance use disorder benefits in the individual and small group markets.

o   By providing more Americans with access to quality health care that includes coverage for mental health and substance use disorder services.

  • A benchmark-based approach is aimed at giving states the flexibility to define essential health benefits in a way that would best meet the needs of their residents. States are allowed to select benchmark plan from options offered in the market, which are equal in scope to a typical employer plan.  


  • In the individual and small group markets, four different actuarial value “metal levels” are outlined in the final rule.   Plans that cover essential health benefits must cover a certain percentage of costs (actuarial value):   60 percent for a bronze plan, 70 percent for a silver plan, 80 percent for a gold plan, and 90 percent for a platinum plan.  These ”metal levels” will allow consumers to compare insurance plans with similar levels of coverage and cost-sharing based on premiums, provider networks, and other factors 


  • The annual amount of cost sharing that individuals will pay across all health plans (preventing insured Americans from facing catastrophic costs associated with an illness or injury) has been limited by this law. 


Note:  While not yet set for 2014, the comparable limit this year is $6,250 for self-only coverage.


  • Accreditation standards for qualified health plans (QHPs) that will be offered through the Health Insurance Marketplaces (also known as Exchanges) are more clearly defined in the final rule.  The Exchanges will be reliable one-stop shops that will provide access to quality, affordable private health insurance choices.


For more information from CMS on this rule, visit:

To view the rule, visit: