What is the Individual Mandate?
In National Federation of Independent Business v. Sebelius, the United States Supreme Court held in part that the individual mandate is constitutional.
The subject of much publicity surrounding this landmark Supreme Court decision, the individual mandate creates an obligation on the part of most Americans to maintain “minimum essential coverage” beginning in 2014. “Minimal essential coverage” includes in part coverage under Medicare, Medicaid, employer-sponsored plans, and health insurance through the Affordable Insurance Exchanges established in 2014.
More information about the individual mandate and minimum essential coverage can be found at Title 26 of the United States Code, Section 5000A.
While the success of the Affordable Care Act remains to be seen, there is no shortage of ways in which the Federal Government hopes to improve coverage.
The following is a sampling of some statutory provisions (42 U.S.C. sections 300gg-1, 2, 3, 4, 5, 6, 7, 8, 9, 11 and 12) designed to make American health better.
- Guaranteed issuance of coverage in the individual and group market
- Guaranteed renewability of coverage
- Prohibition of preexisting condition exclusions or other discrimination based on health status
- Prohibiting discrimination against individual participants and beneficiaries based on health status
- Parity in mental health and substance use disorder benefits
- Comprehensive health insurance coverage
- Prohibition on excessive waiting periods
- Coverage for individuals participating in approved clinical trials
- Disclosure of information
- No lifetime or annual limits
- Prohibition on rescissions
Essential Health Benefits
The United States Department of Health and Human Services (HHS) recently issued the final rule to establish data collection standards necessary to define essential health benefits (EHB).
Beginning in 2014, all non-grandfathered health plans in the individual and small group market, as well as certain other plans, should reflect the following scope of benefits:
- ambulatory patient services
- emergency services
- 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
- pediatric services, including oral and vision care
The entire rule can be viewed here.