ASPE ISSUE BRIEF
Essential Health Benefits: Individual Market Coverage
December 16, 2011
This Issue Brief is available on the Internet at:
http://aspe.hhs.gov/health/reports/2011/IndividualMarket/ib.shtml
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The Affordable Care Act identified ten categories of services and items
included in essential health benefits (EHBs). The ten categories
include: 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; and pediatric services,
including oral and vision care.
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All ten categories of services and items must be covered by insurance
offered in the individual and small group markets as of January 1,
2014.[1]
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According to data on currently marketed plans submitted by health insurance
companies to HealthCare.gov, many individuals and families who purchase their
own health insurance do not currently have coverage for several of the categories
of benefits included in EHBs. [2]
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62 percent of enrollees do not have coverage for maternity services.
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34 percent of enrollees do not have coverage for substance abuse services.
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18 percent of enrollees do not have coverage for mental health services.
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9 percent of enrollees do not have coverage for prescription drugs.
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Americans who buy coverage in the individual market in 2014 will gain
access to essential health benefits. Based on current estimates
of the size of the individual market[3]
and the percent of enrollees in currently marketed plans without coverage
for certain services, coverage of benefits in the individual market may expand
as follows:[4]
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8.7 million Americans will gain maternity coverage.
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4.8 million Americans will gain substance abuse coverage at parity with medical
and surgical benefits.
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2.3 million Americans will gain mental health coverage at parity with medical
and surgical benefits.
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1.3 million Americans will gain prescription drug coverage.
[1] EHBs apply to
non-grandfathered plans in the individual and small group markets both inside
and outside of the Exchanges, Medicaid benchmark and benchmark-equivalent,
and Basic Health Programs.
[2] Data were submitted
by health insurance issuers in to HealthCare.gov in June 2011, including
coverage of benefits in individual market plans and total enrollment in each
individual market plan. These plans cover about 4 million people
there are another 10 million people enrolled in plans that are not open or
did not submit data to HealthCare.gov. Data is only required to be
submitted for plans currently accepting new enrollees that account for more
than 1 percent of an issuers enrollment in a given zip code, and these
numbers only reflect plans that were successfully presented on HealthCare.gov
in June 2011. If the benefits covered in these open plans are similar
to those covered in closed or grandfathered plans, then these numbers can
be extrapolated to the individual market.
[3] The total number of individuals
was calculated by multiplying the proportion of individuals without coverage
from HealthCare.gov with Americas Health Insurance Plans estimate of
14 million enrollees in the individual market (See
http://www.ahip.org/Issues/Individual-Market-Health-Insurance.aspx).
[4] These numbers do not include
estimates of small group market enrollees whose coverage does not currently
include these benefits. Some small group market plans sell riders for
benefits such as maternity, mental health, substance abuse, and prescription
drugs. Individual companies can decide whether or not to purchase any
available riders for these benefits.
To obtain a printed copy of this report, send the title and your mailing
information to:
Health Policy, Room 447D
Assistant Secretary for Planning and Evaluation
U.S. Department of Health and Human Services
200 Independence Ave, SW
Washington, DC 20201
Fax: (202) 690-2524
Email: pic@hhs.gov
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Last updated: 12/16/11