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Big changes ahead in the individual and small group markets (1 - 50)

Starting in 2014, you will be able to offer your employees expanded coverage of their health benefits due to a set of newly proposed rules issued by the Department of Health and Human Services (HHS). The proposed rules touch on a number of key provisions including essential health benefits (EHBs), which are categories of medical services which must be covered. As a result, many Americans will see changes in the design, availability, and cost of health insurance plans beginning in 2014, primarily in the individual and small group markets.   


Essential Health Benefits

Beginning in 2014, the ACA requires that all fully insured non-grandfathered health plans offered in the individual and small group markets — either on or off the exchange — cover a core package of essential health benefits. The EHB package must include items and services within at least the following 10 categories:

  • 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
  • Pediatric services, including oral and vision care
  • Preventive and wellness services and chronic disease management


The Department of Health and Human Services (HHS) has instructed each state to establish its own set of EHBs based on a benchmark plan that reflects the scope of services offered by a "typical employer plan." All plans must offer benefits that are substantially equal to the benefits in the benchmark plan.


In Iowa and South Dakota, Wellmark's Alliance Select Copayment Plus PPO (Iowa) and Wellmark's Blue Select PPO (South Dakota) have been established as the benchmark plans. These plans must also include supplemental coverage of pediatric oral and pediatric vision services. 


NOTE: Large groups, those with 50 or more full-time equivalent employees, are not required to offer Essential Health Benefits. However, should they choose to offer, they need to comply with the requirements as outlined by the ACA.


What are cost-sharing limits for essential health benefits?

Beginning in 2014, health plans must limit the amount consumers pay out-of-pocket for essential health benefits. Specific limits include:

  • Out-of-pocket maximum limits cannot exceed HSA-compatible high-deductible health plan limits in effect for 2014. For point of reference, these amounts are $6,350 for an individual and $12,700 for a family in 2014.
  • Generally, small group market plans may not exceed deductible limits of $2,000 for individual coverage and $4,000 for family coverage in 2014.
  • The annual and lifetime maximum limits are prohibited.


While these regulations are not final, Wellmark is continuing to monitor the regulations and will be offering products that are in compliance with the Affordable Care Act.


Where can I get more information?

Wellmark is here to inform, lead, assist and support you through all the ACA changes. For more information call your Wellmark representative.


Related Information

Blue Cross and Blue Shield Association publications on health care reform issues:
»   12 Myths About Health Insurance pdf image
»   Health Care Spending by Major Payor pdf image
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