Health Insurance Blog

What Does Actuarial Values in Affordable Care Act Health Insurance Mean?

Posted by:
Tim Jackson
on
September 13, 2013
The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average...

The percentage of total average costs for covered benefits that a plan will cover. For example, if a plan has an actuarial value of 70%, on average, you would be responsible for 30% of the costs of all covered benefits. However, you could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms of your insurance policy. https://www.healthcare.gov/glossary/actuarial-value/

HHS is charged with developing guidelines to provide for a de minimis variation in the actuarial valuations used in determining the level of coverage of a plan to account for differences in actuarial estimates. HHS proposed allowing for an actuarial value de minimis variation of 2%. For example, a gold plan [80% actuarial value] could have an actuarial value of 78% to 82%.

What Insurance Companies will be available under the Affordable Care Act?

What are the 10 Statutory Essential Health Benefits Categories?

Benefits and services not included in the definition of essential benefits will not be included in the actuarial value calculation. The ACA provides 10 statutory essential health benefit categories:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • 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 and chronic disease management
  • Pediatric service, including oral and vision care

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