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Obama Administration sets final rule on benefits health insurance companies are required to provide

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Mae Ryan/KPCC

A patient's medical file. The Obama Administration set the final rule regarding what services and items health insurance companies are required to provide on Tuesday.

The Obama Administration issued a final rule on Tuesday regarding a core package of benefits that health insurers must cover, effective in April.

The rule is intended to help consumers shop for and compare health insurance plans by promoting consistency across all plans and making sure that they all cover certain benefits equally.

The rule applies to health insurance providers both in and out of the state insurance marketplaces which are set to open for enrollment later this year, also known as insurance exchanges.

The Center for Consumer Information & Insurance Oversight says essential health benefits "must include items and services within at least the following 10 categories":

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services (including behavioral health treatment)
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Lab services
  9. Preventive care, wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

A statement from the Department of Health and Human Services (HHS) noted that these benefits expand mental health and substance use disorder benefits, as well as federal parity protections, for 62 million more Americans.

Parity protections aim to ensure that insurance coverage for mental health and substance use disorders is "generally comparable to coverage for medical and surgical care," according to the Office of the Assistant Secretary for Planning and Evaluation, which is a part of HHS.

As far as how insurers are required to cover services within these 10 categories, much of that is left to the states.

Also, starting in 2014, health plans that aren't grandfathered in from previous years must meet certain "actuarial values," meaning they'll have to cover a certain percentage of costs. These values have been assigned tiers by the federal government, each named after a metal:

  • A bronze plan covers 60 percent of costs.
  • A silver plan covers 70 percent of costs.
  • A gold plan covers 80 percent of costs.
  • platinum plan covers 90 percent of costs.

Those plans will differ based on premiums, provider networks and other factors, and are intended to help shoppers pick a plan that aligns with how much they'd like to spend on insurance.

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