The introduction of the Affordable Care Act brought about much-needed changes to the healthcare landscape, and the benefits of Obamacare are immeasurable for many – especially the chronically ill. Perhaps one of the most frustrating aspects of American healthcare coverage prior to the introduction of Obamacare was the notion that insurance providers could exclude certain types of patients (or offer only sky-high, unaffordable premiums).

Further, carriers had virtually unlimited discretion in what their policies covered and didn’t cover – leaving many in a six-figure loophole following a catastrophic uncovered event.

Under Obamacare, there are now ten essential areas of coverage, known as “essential health benefits,” that must be included in every plan without exception. Meaning that those seeking insurance coverage can rest easy knowing that the most common medical scenarios will be included – and even some of the less-common situations as well.

10 Essential Areas of Coverage

Anyone with the benefit of an Obamacare plan is covered for the following health situations:

1. Ambulatory Services

Ambulatory care refers to medical services performed on an outpatient basis, therefore not requiring admission to a hospital. It is an umbrella term that includes a number of different healthcare interactions, including renal dialysis, primary care appointments, chemotherapy, ultrasounds, colonoscopies or minor surgical procedures, to name a few.

2. Emergency Services

Obviously, this includes a trip to the emergency room for an urgent or critical matter. This type of service is further defined to include the evaluation of the emergency situation by medical staff, as well as treatment to ensure that the medical event does not worsen.

Coverage for transport ancillary to emergency services (e.g., by ambulance or life flight) must be deemed “medically necessary” by the insurance carrier reviewing the claim, which is generally documented by the treating emergency department physician at the time of the patient interaction.

3. Hospitalization  

Some medical conditions require a lengthy stay in intensive care, critical care or the general hospital floor. The term is meant to include the situation where a patient is admitted to the hospital for at least one overnight stay. However, some states consider hospitalization to occur after two or more overnight stays – while a one-night stay is considered outpatient. Regardless, both scenarios are covered as an essential health benefit under Obamacare.

4. Maternity and Newborn Care

One of the most lauded components of healthcare coverage was full insurance for the costs of maternity and newborn care. Under the Affordable Care Act, compliant insurance plans must include this, including preconception examinations and counseling, prenatal care for the duration of the pregnancy, postnatal care for mother and baby, well-baby checkups, lactation support, breast pump equipment, and assistance with barriers to health (e.g., smoking cessation, counseling for post-partum depression, screening and assistance for women facing intimate partner violence).

5. Prescription Drugs

Medication coverage is another hallmark of the Affordable Care Act, as plans are mandated to provide insurance for the (increasing) costs of medications. The degrees of coverage under this prong of essential health benefits vary from policy to policy, however, all plans must include some degree of assistance.

Also, if you enroll in a plan that does not cover a medication you are used to taking, the insurance provider may be able to make an exception if (1) similar drugs included in the plan will not be effective, or; (2) similar drugs are likely to cause an adverse reaction.

If you qualify for an exception, the insurance provider will treat the drug as “covered” under the plan, but will likely also charge a co-pay.

6. Rehabilitative and Habilitative Services

Rehabilitative services are those that help a person regain a skill (lost due to injury or illness), while habilitative services are those that introduce a physical or cognitive skill not yet acquired (due to disability or congenital condition). For patients in need of rehabilitation, this includes physical therapy and/or pain management, prosthetics, wheelchairs or orthotics. Rehabilitative services also include interventions designed to keep a chronic condition from deteriorating over time (e.g., cerebral palsy).

Habilitative services covered under Obamacare plans mostly apply to children born with a disability of some sort and are working on gaining skills they have not yet mastered. This could, again, including physical therapy to learn gross and fine motor skills, feeding therapy, and any necessary equipment.

7. Laboratory Services

Laboratory services can be ancillary to virtually any other category of essential health benefits and are often an irreplaceable component of uncovering a diagnosis and ultimately treating the problem. Therefore, lab testing of blood, urine, skin, biopsied material and any other test necessary to address a medical issue is covered under Affordable Care Act-compliant plans.

8. Behavioral Health

Another huge victory under the Affordable Care Act is coverage for behavioral health issues, including treatment for mental health, psychiatric drugs, substance use disorder treatment (including safe detoxification), counseling services and inpatient mental health treatment. There is no lifetime limit on behavioral health coverage (or any essential health benefit), and insurers cannot deny coverage to anyone with a pre-existing mental health or behavioral health condition.

9. Preventative Health and Chronic Illness Management

Obamacare plans must cover all routine physicals, preventative screening, and wellness examinations. This category also includes immunizations, women’s preventative care (e.g., mammograms, cervical cancer testing, contraceptive counseling, and medication), and both vision and dental care for children.

10. Pediatric Services

The final benefit to Obamacare is the host of services for pediatric patients that must be covered under compliant plans. This includes all newborn screens, behavioral evaluations for conditions like autism or ADHD, adolescent screening concerning STI’s and drug/alcohol use, and gynecological services for female adolescent and teenage patients.

How These Requirements Changed Healthcare

The Affordable Care Act brought about unprecedented change to the stagnant American healthcare landscape. Prior to its enactment, an estimated three out of every five mothers-to-be did not have coverage for routine prenatal care.

A staggering one-third of all those suffering from a mental health condition did not have coverage, while approximately ten percent of Americans had no coverage for prescription drugs. Now, more and more people are accessing affordable and thorough healthcare – and the benefits of Obamacare continue to unveil nearly a decade later.

As you consider your healthcare coverage options, give Fiorella Insurance a call today!

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