What is Non-Discrimination in Essential Health Benefit Design?
Most health insurance plans offered to people in the individual and small group (i.e., small business) markets must include an “essential health benefits” package.
“Essential health benefits” consist of 10 categories of items or services that provide: prescription drug coverage, emergency services, hospitalization, outpatient services, maternity and newborn care, pediatric services (including oral and vision care), laboratory services, mental health and substance use disorder services, rehabilitative and habilitative services, and preventive and wellness services.
Health insurance companies are not permitted to design these benefits in a way that discriminates (or has the effect of discriminating) against anyone on the basis of age, expected length of life, present or predicted disability, quality of life, or other health conditions. Consumers are also protected from discrimination on the basis of race, color, national origin, gender identity, or sexual orientation.
Common features of health insurance benefits
Health insurance companies commonly use the following features in designing benefits:
- Benefit Exclusions
- Cost-sharing provisions
- Definitions of Medical Necessity
- Prescription drug formularies
- Visit limits
- Benefit substitutions
While many insurers use these properly based on medical evidence, patient need, or other factors, some features may be administered in a discriminatory manner.
