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The Wagner Law Group Description 

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The਍ഀ Wagner Law Group, A Professional Corporation, is a nationally਍ഀ recognized ERISA & employee benefits, estate planning,਍ഀ employment, labor & human resources practice. 

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Established਍ഀ in 1996, The Wagner Law Group has 22 attorneys engaged਍ഀ exclusively in employee benefits, estate planning and਍ഀ employment law. Five of our attorneys are AV rated by਍ഀ Martindale-Hubbell as having very high to preeminent legal abilities਍ഀ and ethical standards. The firm is among the largest ERISA boutiques਍ഀ in the country. Our practice is national in scope, with clients in਍ഀ more than 40 states and several foreign countries.

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Contact਍ഀ Info

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The਍ഀ Wagner Law Group

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  Integrity਍ഀ | Excellence

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Massachusetts਍ഀ Office 

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Tel:਍ഀ (617) 357-5200 

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Fax:਍ഀ (617) 357-5250 

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99਍ഀ Summer Street 

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13th਍ഀ Floor

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Boston,਍ഀ MA 02110

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਍ഀ Florida Office 

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Tel:਍ഀ (561) 293-3590
਍ഀ Fax: (561) 293-3591
਍ഀ 7108 Fairway Drive
਍ഀ Suite 125
਍ഀ Palm Beach Gardens, FL 33418

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San਍ഀ Francisco Office

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Tel:਍ഀ (415) 625-0002

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Fax:਍ഀ (415) 829-4385

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315਍ഀ Montgomery Street

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Suite਍ഀ 902

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San਍ഀ Francisco, CA 94104

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www.wagnerlawgroup.com

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February 28, 2013 

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 State and Federal Law਍ഀ Alert

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HHS Issues Final Regulations਍ഀ on Essential Health Benefits and Plan Value under PPACA 

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The Department of Health and਍ഀ Human Services ("HHS") has issued final regulations on the਍ഀ essential health benefits ("EHBs") and actuarial value਍ഀ requirements contained in the Patient Protection and Affordable Care਍ഀ Act ("PPACA").

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Essential Health Benefits. Beginning in 2014, health plans offered in the਍ഀ individual and small group markets, including "Qualified Health਍ഀ Plans" offered through Exchanges, must cover the following ten਍ഀ categories of EHBs: 

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  • ambulatory਍ഀ patient services,
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  • emergency਍ഀ services,
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  • hospitalization,
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  • maternity਍ഀ and newborn care,
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  • mental਍ഀ health and substance use disorder services,
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  • prescription਍ഀ drugs,
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  • rehabilitative਍ഀ and habilitative services and devices,
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  • lab਍ഀ services,
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  • preventive਍ഀ and wellness services and chronic disease management, and
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  • pediatric਍ഀ services. 
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The final regulations base਍ഀ required EHBs on a state-specific benchmark plan. The state options਍ഀ for benchmarks include: 

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  1. the largest਍ഀ plan by enrollment in any of the three largest small group਍ഀ insurance products in the state;
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  3. any of the਍ഀ three largest state employee health benefit plans;
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  5. any of the਍ഀ three largest Federal Employees Health Benefits Programs; or
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  7. the largest਍ഀ insured non-Medicaid HMO in the state. 
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All plans offered within a਍ഀ state that are subject to the EHB requirements must contain benefits਍ഀ substantially equal in scope to the benefits offered by the selected਍ഀ benchmark plan. For states that fail to select a benchmark plan, the਍ഀ default benchmark plan will be the largest plan in the largest਍ഀ product within the state's small group market.

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The final regulations਍ഀ contain standards to protect consumers against discrimination and਍ഀ ensure that benchmark plans offer a full suite of EHB benefits and਍ഀ services. In particular, the final rule: 

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  • prohibits਍ഀ discriminatory benefit designs;
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  • includes਍ഀ special standards and options for coverage of benefits not਍ഀ typically covered by individual and small group policies today;਍ഀ and
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  • includes਍ഀ standards for prescription drug coverage to ensure that਍ഀ individuals have access to needed prescription਍ഀ medications. 
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Actuarial Value. The final regulations outline actuarial levels਍ഀ in the individual and small group markets, which helps consumers to਍ഀ distinguish between health plans offering different levels of਍ഀ coverage. Beginning in 2014, health plans that offer EHBs must cover਍ഀ a certain percentage of costs, known as actuarial value or਍ഀ "metal levels." PPACA requires non-grandfathered health਍ഀ plans to meet one of the following four "metal" levels: 60਍ഀ percent for a bronze plan, 70 percent for a silver plan, 80 percent਍ഀ for a gold plan and 90 percent for a platinum plan. The metal levels਍ഀ are also intended to help consumers in comparing and selecting health਍ഀ plans by allowing a potential enrollee to compare the relative਍ഀ payment generosity of available plans. HHS is finalizing an actuarial਍ഀ value calculator that it will make available to the public to assist਍ഀ in determining a health plan's actuarial value.

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This Newsletter is protected by copyright. Material਍ഀ appearing herein may be reproduced with appropriate credit.

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Pursuant to Internal Revenue Service Circular 230, we਍ഀ hereby inform you that any advice set forth herein with respect to US਍ഀ federal tax issues is not intended or written by The Wagner Law Group਍ഀ to be used and cannot be used, by you or any taxpayer, for the purpose਍ഀ of avoiding penalties that may be imposed on you or any other person਍ഀ under the Internal Revenue Code.

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This Newsletter is provided for information purposes by਍ഀ The Wagner Law Group to clients and others who may be interested in the਍ഀ subject matter, and may not be relied upon as specific legal਍ഀ advice.  This material is not to be construed as legal advice or਍ഀ legal opinions on specific facts. Under the Rules of the Supreme਍ഀ Judicial Court of Massachusetts, this material may be considered਍ഀ advertising.

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