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This entry was published on 2020-01-10
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SECTION 4306-H
Essential health benefits package and limit on cost-sharing
Insurance (ISC) CHAPTER 28, ARTICLE 43
§ 4306-h. Essential health benefits package and limit on cost-sharing.
(a) (1) For purposes of this article, "essential health benefits" shall
mean the following categories of benefits:

(A) ambulatory patient services;

(B) emergency services;

(C) hospitalization;

(D) maternity and newborn care;

(E) mental health and substance use disorder services, including
behavioral health treatment;

(F) prescription drugs;

(G) rehabilitative and habilitative services and devices;

(H) laboratory services;

(I) preventive and wellness services and chronic disease management;
and

(J) pediatric services, including oral and vision care.

(2) A corporation shall not be required to provide coverage for
pediatric oral services as an essential health benefit if:

(A) for coverage offered through the exchange established by this
state, the exchange has determined sufficient coverage of the pediatric
oral benefit is available through stand-alone dental plans certified by
the exchange; or

(B) for coverage offered outside the exchange, the corporation obtains
reasonable written assurance that the individual or group has obtained a
stand-alone dental plan that has been approved by the superintendent as
meeting exchange certification standards.

(b) (1) Every individual and small group contract that provides
hospital, surgical, or medical expense coverage and is not a
grandfathered health plan shall provide coverage that meets the
actuarial requirements of one of the following levels of coverage:

(A) Bronze Level. A plan in the bronze level shall provide a level of
coverage that is designed to provide benefits that are actuarially
equivalent to sixty percent of the full actuarial value of the benefits
provided under the plan;

(B) Silver Level. A plan in the silver level shall provide a level of
coverage that is designed to provide benefits that are actuarially
equivalent to seventy percent of the full actuarial value of the
benefits provided under the plan;

(C) Gold Level. A plan in the gold level shall provide a level of
coverage that is designed to provide benefits that are actuarially
equivalent to eighty percent of the full actuarial value of the benefits
provided under the plan; or

(D) Platinum Level. A plan in the platinum level shall provide a level
of coverage that is designed to provide benefits that are actuarially
equivalent to ninety percent of the full actuarial value of the benefits
provided under the plan.

(2) The superintendent may provide for a variation in the actuarial
values used in determining the level of coverage of a plan to account
for the differences in actuarial estimates.

(3) Every student accident and health insurance contract shall provide
coverage that meets at least sixty percent of the full actuarial value
of the benefits provided under the contract. The contract's schedule of
benefits shall include the level as described in paragraph one of this
subsection nearest to, but below the actual actuarial value.

(c) Every individual or group contract that provides hospital,
surgical, or medical expense coverage and is not a grandfathered health
plan, and every student accident and health insurance contract shall
limit the insured's cost-sharing for in-network services in a contract
year to not more than the maximum out-of-pocket amount determined by the
superintendent for all contracts subject to this section. Such amount
shall not exceed any annual out-of-pocket limit on cost-sharing set by
the United States secretary of health and human services, if available.

(d) The superintendent may require the use of model language
describing the coverage requirements for any form that is subject to the
approval of the superintendent pursuant to section four thousand three
hundred eight of this article.

(e) For purposes of this section:

(1) "actuarial value" means the percentage of the total expected
payments by the corporation for benefits provided to a standard
population, without regard to the population to whom the corporation
actually provides benefits;

(2) "cost-sharing" means annual deductibles, coinsurance, copayments,
or similar charges, for covered services;

(3) "essential health benefits package" means coverage that:

(A) provides for essential health benefits;

(B) limits cost-sharing for such coverage in accordance with
subsection (c) of this section; and

(C) provides one of the levels of coverage described in subsection (b)
of this section;

(4) "grandfathered health plan" means coverage provided by a
corporation in which an individual was enrolled on March twenty-third,
two thousand ten for as long as the coverage maintains grandfathered
status in accordance with section 1251(e) of the Affordable Care Act, 42
U.S.C. § 18011(e);

(5) "small group" means a group of one hundred or fewer employees or
members exclusive of spouses and dependents; and

(6) "student accident and health insurance" shall have the meaning set
forth in subsection (a) of section three thousand two hundred forty of
this chapter.