The Affordable Care Act (ACA) requires individuals and small group health plans to offer a package of covered services called essential health benefits. These services must be covered by plans both in and out of the government-run health insurance marketplace.
If a health plan pays for or reimburses a plan member for a particular item or service, that item or service is considered a covered benefit. The amount that the insurance company pays for the item or service (and the amount that you are required to pay for it) varies by service and by insurance companies and plan types. This means that some services are subject to deductibles, coinsurance and copays, but if your health plan provides even some benefits for it, it is a covered service.
Four levels of coverage are available for health plans sold in the health insurance marketplace beginning in 2014.
- Bronze plans pay 60% for covered services
- Silver plans pay 70% for covered services
- Gold plans pay 80% for covered services
- Platinum plans pay 90% for covered services
Health plan premiums are higher as the plan pays more toward covered services (i.e., the higher metallic level plans have higher premiums). Regardless of the type of plan, you will have some level of coverage for the essential health benefits required by the ACA.
Health plans sold privately through RW Insurance may have different deductibles, copays and coinsurance for covered services, but they too must provide coverage for the essential health benefits beginning in 2014.
Essential Health Benefits
Your health plan, whether it is purchased from the health insurance exchange or privately through RW Insurance, must include coverage for essential health benefits. The essential health benefits must include items and services within the following ten categories, or more:
- Ambulatory patient services: Care you receive without being admitted to a hospital, such as at a doctor’s office, clinic or same-day (outpatient) surgery. This also includes home health services and hospice care up to a certain number of days.
- Emergency services: Care you receive in an emergency room or in an emergency situation.
- Hospitalization: Care you receive in a hospital, including care from doctors, nurses and other hospital staff, lab tests, medications and room and board. Also includes surgeries, transplants and care in a skilled nursing facility up to a certain number of days.
- Maternity and newborn care: Care women receive during pregnancy and throughout labor, delivery, post-delivery and care for newborn babies.
- Mental health and substance abuse services and behavioral health treatment: Inpatient and outpatient care to evaluate, diagnose and treat a mental health condition or substance abuse problem.
- Prescription drugs: Medications prescribed by a doctor to treat an illness or condition.
- Rehabilitative services and devices: Services and devices to help you gain or recover mental and physical skills lost to injury, disability or chronic condition. Includes a certain number of visits for physical or occupational therapy, chiropractic care, speech therapy and cardiac or pulmonary rehabilitation.
- Laboratory services: Testing for purposes of diagnosing an illness, injury or condition or to monitor the effectiveness of a treatment. Also includes some preventive screenings such as breast cancer screenings at no cost.
- Preventive and wellness services and chronic disease treatment: Preventive care such as physicals, immunizations and cancer screenings designed to prevent or detect certain conditions. Also includes care for chronic conditions like diabetes and asthma.
- Pediatric services, including oral and vision care: Care provided to infants and children, including well-child visits, vaccines and immunizations. Also includes dental and vision care for children younger than age 19, for two routine dental exams, an eye exam and corrective lenses annually.
Other New Coverage Requirements
Beginning in 2014, all health plans comply with the following requirements:
- You cannot be turned down or charged more because you are sick or have a health condition.
- Health plans cannot arbitrarily cancel your coverage because you get sick.
- If you are under 26 years old, you can join, remain on or return to a parent’s health plan even if you are married, not living with your parents, attending school, financially independent or eligible to enroll in your employer’s plan.
- Health plans (including grandfathered plans) cannot impose lifetime or yearly dollar limits on coverage for essential health benefits.
- Health plans cannot require higher copayments or coinsurance if you get emergency care from an out-of-network hospital, and you cannot be required to get prior approval before getting emergency room services from a hospital that is out-of-network.
These changes do not apply to individual or group health plans created or bought before March 23, 2010, unless otherwise noted. These are known as grandfathered plans. If a plan has made any changes since March 23, 2010, it will lose its grandfathered status.
Many health plans are required to cover certain preventive services at no cost to you. You also may be eligible for free preventive screenings like blood pressure and cholesterol tests, mammograms, colonoscopies and more, as well as certain vaccines and new preventive services for women. These new no-cost services do not apply to plans created or bought before March 23, 2010 (unless those plans have changed in any way since that date).
Health care reform is complicated and you should not go it alone. RW Insurance can help you determine if you have a grandfathered plan or if you have to purchase a new plan. If you are looking to purchase an individual or small group health plan, we can help you navigate the insurance exchange, find out if you are eligible for any financial assistance, and help you apply for coverage. We also have access to plans outside of the insurance exchange that may better suit your needs.
