§ 3217-I — Essential health benefits package and limit on cost-sharing

§ 3217-i. Essential health benefits package and limit on cost-sharing.\n(a) (1) For purposes of this article, "essential health benefits" shall\nmean the following categories of benefits:\n (A) ambulatory patient services;\n (B) emergency services;\n (C) hospitalization;\n (D) maternity and newborn care;\n (E) mental health and substance use disorder services, including\nbehavioral health treatment;\n (F) prescription drugs;\n (G) rehabilitative and habilitative services and devices;\n (H) laboratory services;\n (I) preventive and wellness services and chronic disease management;\nand\n (J) pediatric services, including oral and vision care.\n (2) An insurer shall not be required to provide coverage for pediatric\noral services as an essential health benefit if:\n (A) for coverage offered through the exchange established by this\nstate, the exchange has determined sufficient coverage of the pediatric\noral benefit is available through stand-alone dental plans certified by\nthe exchange; or\n (B) for coverage offered outside the exchange, the insurer obtains\nreasonable written assurance that the individual or group has obtained a\nstand-alone dental plan that has been approved by the superintendent as\nmeeting exchange certification standards.\n (b) (1) Every individual and small group accident and health insurance\npolicy that provides hospital, surgical, or medical expense coverage and\nis not a grandfathered health plan shall provide coverage that meets the\nactuarial requirements of one of the following levels of coverage:\n (A) Bronze Level. A plan in the bronze level shall provide a level of\ncoverage that is designed to provide benefits that are actuarially\nequivalent to sixty percent of the full actuarial value of the benefits\nprovided under the plan;\n (B) Silver Level. A plan in the silver level shall provide a level of\ncoverage that is designed to provide benefits that are actuarially\nequivalent to seventy percent of the full actuarial value of the\nbenefits provided under the plan;\n (C) Gold Level. A plan in the gold level shall provide a level of\ncoverage that is designed to provide benefits that are actuarially\nequivalent to eighty percent of the full actuarial value of the benefits\nprovided under the plan; or\n (D) Platinum Level. A plan in the platinum level shall provide a level\nof coverage that is designed to provide benefits that are actuarially\nequivalent to ninety percent of the full actuarial value of the benefits\nprovided under the plan.\n (2) The superintendent may provide for a variation in the actuarial\nvalues used in determining the level of coverage of a plan to account\nfor the differences in actuarial estimates.\n (3) Every student accident and health insurance policy shall provide\ncoverage that meets at least sixty percent of the full actuarial value\nof the benefits provided under the policy. The policy's schedule of\nbenefits shall include the level as described in paragraph one of this\nsubsection nearest to, but below the actual actuarial value.\n (c) Every individual or group accident and health insurance policy\nthat provides hospital, surgical, or medical expense coverage and is not\na grandfathered health plan, and every student accident and health\ninsurance policy shall limit the insured's cost-sharing for in-network\nservices in a policy year to not more than the maximum out-of-pocket\namount determined by the superintendent for all policies subject to this\nsection. Such amount shall not exceed any annual out-of-pocket limit on\ncost-sharing set by the United States secretary of health and human\nservices, if available.\n (d) The superintendent may require the use of model language\ndescribing the coverage requirements for any accident and health\ninsurance policy form that is subject to the superintendent's approval\npursuant to section three thousand two hundred one of this article.\n (e) For purposes of this section:\n (1) "actuarial value" means the percentage of the total expected\npayments by the insurer for benefits provided to a standard population,\nwithout regard to the population to whom the insurer actually provides\nbenefits;\n (2) "cost-sharing" means annual deductibles, coinsurance, copayments,\nor similar charges, for covered services;\n (3) "essential health benefits package" means coverage that:\n (A) provides for essential health benefits;\n (B) limits cost-sharing for such coverage in accordance with\nsubsection (c) of this section; and\n (C) provides one of the levels of coverage described in subsection (b)\nof this section;\n (4) "grandfathered health plan" means coverage provided by an insurer\nin which an individual was enrolled on March twenty-third, two thousand\nten for as long as the coverage maintains grandfathered status in\naccordance with section 1251(e) of the Affordable Care Act, 42 U.S.C. §\n18011(e);\n (5) "small group" means a group of one hundred or fewer employees or\nmembers exclusive of spouses and dependents; and\n (6) "student accident and health insurance" shall have the meaning set\nforth in subsection (a) of section three thousand two hundred forty of\nthis article.\n