What Everyone Can Expect from ACA Essential Benefits

What Everyone Can Expect from ACA Essential Benefits

November Newsletter_ACA BenefitsThe Affordable Care Act outlines several standards that all insurers must meet, and it also requires a set of essential health benefits to be a part of the plans offered. Before the new health care law was passed, experts said insurers attempted to lower premiums by cutting benefits. The essential benefits are meant to set a standard, and any plan that does not include them could not be considered true health insurance. Researchers found that less than two percent of existing plans today offer all 10 essential benefits. The average plan offers about 75 percent of the inclusions. Before purchasing health coverage or changing plans, it is important to know what these benefits are.


Prescription Medications This is currently an option with most plans but not mandatory. However, the new law will make all small group and individual plans cover at least one drug in each class and category of the United States Pharmacopeia. Prescription costs will count toward upfront expense caps.


Ambulatory Services This is also called outpatient care, and it happens when a person goes in to be treated and leaves the same day. Most health plans currently offer this form of coverage, but the new law will ensure that network sizes for these offerings are sufficient.


Mental Health The majority of existing plans do not cover behavioral or mental health services, but the new law will change that. Coverage will be limited to a specific number of sessions, and patients may be billed a small amount for each one.


Rehabilitative Services People who suffer injuries or illnesses today may or may not have rehabilitative services on their policies. The new plans must cover these services and equipment items such as braces, canes, wheelchairs, walkers and other essential devices. Habilitative services will also be added, and these are rarely covered in existing plans. They help people cope with the slow effects of long-term illnesses such as multiple sclerosis.


Hospitalization With the new law, an insurer must provide coverage for hospital stays. However, patients may be responsible for 20 percent or more of the total bill if an out-of-pocket limit has not been reached. With average hospital stays often exceeding $2,000 per day, experts felt that this was an important inclusion.


Emergency Care Under most existing plans, emergency care is covered. Many providers charge a fee for out-of-network emergency services, or they may require pre-authorization. With the new law, these two requirements will no longer exist.


Maternity And Newborn Care The new law will classify prenatal care as a preventative service, so there will be no extra cost. It will also require all insurers to cover childbirth and infant care.


Pediatric Care Although few current health plans cover dental, orthodontic and vision care, the new law will set provisions for those areas for kids under the age of 19. Each one will be able to receive orthodontic care, fillings, x-rays and two teeth cleaning sessions per year. They will also receive an eye exam and one pair of contacts or glasses per year.


Wellness And Preventative Services The purpose of this benefit is to keep the number of needs-related doctor visits down. Experts say that if people make healthier choices for their lifestyles, the need for serious medical care will lessen. Every person will be allowed one free wellness visit per year, and 50 other preventative health services are also available.


Laboratory Services Preventative screening tests will be required as part of the new law, but patients may still be billed a small amount for diagnostic tests. Costs may range from $20 to up to 30 percent of an MRI. Health insurance plans will certainly see several changes as the new law takes effect. For answers to any questions about existing coverage or changing plans, discuss concerns with an agent.