include guaranteed issue and prohibitions on exclusions based on pre-existing conditions and health risks, prohibitions on lifetime and annual
benefit limits, as well as requirements for plan actuarial values, medical loss
ratios, risk adjustments, and data reporting.18 The exchanges may be
established or operated by a state, the federal government, or a federal-state
cooperative arrangement of various types.19 This article refers to the ACA
plans required to meet these conditions as “ACA plans,” whether they are
offered through an exchange or in the ordinary insurance market.
To assure consistency in benefit design, the ACA requires ACA plans
to cover ten categories of health services, called Essential Health Benefits
(“EHB”).20 The Act defines EHB as ten broad categories of benefits:
( 1) Ambulatory patient services;
(2) Emergency services;
(4) Maternity and newborn care;
(5) Mental health and substance use disorder services, including
behavioral health treatment;
(6) Prescription drugs;
287, and 113-291) (establishing the Exchanges and noting that these requirements do not
apply to large group plans or employer-sponsored self-insured or grandfathered plans).
18. 45 C.F.R. Pt. 155 (2014) (establishing the exchanges); 45 C.F.R. Pt. 156 (2014)
(listing the requirements for insurers offering qualified health plans on exchanges); 42
U.S. C. A § 300gg (prohibiting discriminatory premium rates); § 300gg- 1 (requiring health
insurance issuers to accept every employer and individual that applies for coverage); §
300gg-3 (prohibiting preexisting condition exclusion); § 300gg-2 (guaranteeing that health
insurance coverage is renewable); § 300gg-5 (requiring non-discrimination in health care); §
300gg-11 (prohibiting establishment of annual/lifetime limits on the dollar value of
benefits); § 300gg-13 (requiring minimum coverage for preventive health services and
prohibiting cost sharing in various situations); § 300gg-14 (allowing dependent children to
stay on their parents health plan until 26 years of age); § 300gg-19 (requiring an effective
internal appeals process); 42 U.S. C. A. § 18061 (West, WestlawNext through P.L. 113-296,
excluding P.L. 113-235, 113-287, and 113-291) (providing a transitional reinsurance
program); 42 U.S. C. A. § 18062 (establishing a program of risk corridors); 42 U.S. C. A. §
18063 (establishing criteria and methods for low and high actuarial risk plans); 42 U.S. C. A.
§ 18071 (implementing income-based cost sharing reductions). ACA plans meeting the
conditions can be approved as “qualified plans” that can be sold through the marketplace
exchanges. § 18031(c) (establishing criteria for qualified health plans).
19. State Health Insurance Marketplace Types, 2015, KAISER FAM. FOUND.,
visited Apr. 13, 2015); Sarah J. Dash & Amy Thomas, New State-Based Marketplaces
Unlikely in 2015, but Technology Challenges Create More Shades of Gray, THE
COMMONWEALTH FUND BLOG (May 1, 2014), http://www.commonwealthfund.org/
publications/blog/2014/may/new-state-based-marketplaces-unlikely-in-2015; accord Abbe
R. Gluck, Intrastatutory Federalism and Statutory Interpretation: State Implementation of
Federal Law in Health Reform and Beyond, 121 Yale L.J. 534 (2011) (discussing variations
in exchanges and Medicaid programs as examples of evolving conceptions of federalism).
20. § 18022(b)( 1).