Benefit and Coverage Rules Under the ACA: California vs. Federal Provisions

Kelch Policy Group

Health insurance products under the ACA are subject to federal and state regulation. This table compares the rules for essential benefits, levels of coverage, and cost sharing.

March 2014

Since passage of the federal Affordable Care Act (ACA) in 2010, California has enacted implementing state legislation in key areas, including establishment of a state-administered exchange, health insurance premium rate review, benefit standards and cost-sharing limits, and detailed rules for the offering and sale of private coverage to individuals and small employer groups. These measures were taken in the context of pre-existing state laws and programs, requiring policymakers to analyze and reconcile state and federal standards.

This overview compares California law and the ACA regarding benefit and coverage rules effective January 1, 2014. The following topics are presented in a side-by-side table:

  • Essential health benefits, including preventive services, prescription drugs, habilitative services, mental health and substance abuse services, pediatric dental coverage, and emergency care. The chart also covers information about prohibition of discrimination and about annual and lifetime dollar limits on coverage.
  • Consumer cost sharing, including annual out-of-pocket maximum and limits on deductibles.
  • Levels of coverage, including actuarial values, definition of catastrophic plan, rules for mandatory offerings, and product pricing information.

The complete table is available as a Document Download.