State RegulationsTX specificDifficulty 2/5
The essential health benefit requirement of ACA Section 1302 applies to which of the following?
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Answer & full 3-part explanation (select an option above, or peek)
Why A is correct
Under ACA Section 1302, the duty to cover the essential health benefit categories falls on non-grandfathered health plans in the individual and small group markets. The requirement is not limited to plans sold through the Marketplace, and it does not extend to large-employer group health plans or to Medicare supplement policies, which are governed by separate standards. For a Texas agent, the key point is that a non-grandfathered individual plan bought directly from an insurer must still cover the essential health benefits.
Why the other options are wrong
- B) The requirement is broader than the Marketplace. Non-grandfathered individual and small group plans sold off the Marketplace must also cover the essential health benefits.
- C) Large-employer group health plans are not subject to the essential health benefit requirement, although they are subject to other ACA market reforms.
- D) Medicare supplement policies are governed by federal Medicare supplement standards and the Texas rules at 28 TAC 3.3301-3.3310, 3.3312-3.3313, and 3.3315-3.3325, not by the essential health benefit requirement.
Memory hook
EHB attaches to non-grandfathered individual and small group plans, on or off the Marketplace.