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Essential Health Benefits

UPDATE - December 14, 2012 - A letter from Nevada Insurance Commissioner Scott J. Kipper regarding the Essential Health Benefits

October 1, 2012 - Nevada was asked to choose an Essential Health Benefits plan. You can read a letter from Nevada Insurance Commissioner Scott Kipper regarding the Essential Health Benefits here. 

Read public comment regarding the Essential Health Benefits. 

The essential health benefits plan for Nevada will be the benchmark set of health care services that will be required in all individual and small group health insurance plans starting in 2014. Nevada selected the following plan:

Nevada EHB Benchmark Plan

Guide to Reviewing Nevada’s Essential Health Benefits Benchmark Plan

Nevada’s essential health benefits (EHB)-benchmark plan is based on 2012 plan designs, and therefore does not necessarily reflect requirements effective for plan years beginning on or after January 1, 2014. Therefore, when designing plans that are substantially equal to the EHB-benchmark plan beginning January 1, 2014, issuers may need to design plan benefits, including coverage and limitations, to comply with these requirements and limitations, including but not limited to, the following:

Annual and Lifetime Dollar Limits

The EHB-benchmark plan displayed may include annual and/or lifetime dollar limits; however, in accordance with 45 CFR 147.126, these limits cannot be applied to the essential health benefits. Annual and lifetime dollar limits can be converted to actuarially equivalent treatment or service limits.

Excluded Benefits

Pursuant to 45 CFR 156.115, the following benefits are excluded from EHB even though an EHB-benchmark plan may cover them: routine non-pediatric dental services, routine non- pediatric eye exam services, long-term/custodial nursing home care benefits, and/or non- medically necessary orthodontia. Please also note that although the EHB-benchmark plan may cover abortion services, pursuant to section 1303(b)(1)(A) of the Affordable Care Act, a QHP issuer is not required to cover these services. Section 156.115(c) provides that no health plan is required to cover abortion services as part of the requirement to cover EHB. Nothing in this provision impedes an issuer’s ability to choose to cover abortion services.

Habilitative Services

Nevada requires habilitative services to be offered at parity with rehabilitative services.

Coverage Limits

Pursuant to 45 CFR 156.115(a)(2), with the exception of coverage for pediatric services, a plan may not exclude an enrollee from coverage in an entire EHB category, regardless of whether such limits exist in the EHB-benchmark plan. For example, a plan may not exclude dependent children from the category of maternity and newborn coverage.

Nevada Mandated Benefits

For purposes of determining EHB, state-required benefits (or mandates) are considered to include only requirements that a health plan cover specific care, treatment, or services. Provider mandates, which require a health plan to reimburse specific health care professionals who render a covered service within their scope of practice, are not considered to be state-required benefits for purposes of EHB coverage. Similarly, dependent mandates, which require a health plan to define dependents in a specific manner or to cover dependents under certain circumstances (e.g., newborn coverage, adopted children, domestic partners, and disabled children) are not considered state-required benefits. Finally, state anti- discrimination requirements relating to service delivery method (e.g., telemedicine) are not considered state- required benefits.

Mental Health Parity

The EHB-benchmark plan displayed may not comply with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). However, as described in 45 CFR 156.115(a)(3), EHB plans must comply with the standards implemented under MHPAEA.

EHB-Benchmark Plan Prescription Drugs by Category and Class

Please note that in some cases a category is listed without a United States Pharmacopeia (USP) class because there are some drugs within the category that have not been assigned to a specific class.

Please also note that where the EHB-benchmark plan does not include coverage in a USP category and/or class, pursuant to 45 CFR 156.122, one drug would have to be offered in that USP category and/or class.

Plans must offer the greater of one drug in every USP category and class or the number of drugs in each USP category and class offered by the EHB- benchmark plan.

Preventive Services

The EHB-benchmark plan displayed may not offer the preventive services described in 45 CFR
147.130. However, as described in 45 CFR 156.115(a)(4), EHB plans must comply with that section.