The introduction of the Patient Protection and Affordable Care Act – commonly referred to as the Affordable Care Act and the subsequent establishment of the health insurance marketplace brought about much-needed changes to the healthcare landscape, and the benefits of Obamacare are immeasurable for many – especially the chronically ill, young adults, those with pre existing conditions, those at or near the federal poverty level, the middle class and even senior citizens. Perhaps one of the most frustrating aspects of American healthcare coverage prior to the introduction of Obamacare was the notion that health insurance companies could exclude certain types of patients (or offer only sky-high, unaffordable premiums) pre-existing conditions.
Further, health insurance carriers had virtually unlimited discretion in what their policies covered and didn’t cover – leaving many in a six-figure debt loophole following a catastrophic uncovered medical event.
Affordable Health Care – Essential Health Care Benefits
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.
ACA is Still the Law of the Land
The individual mandate has faced numerous legal challenges. But despite many legal challenges, the supreme court has found it to be constitutional. Did Obamacare Improve Healthcare in the U.S.? The ACA has largely functioned as designed. Boiled down to its simplest, the issue is that more and better coverage costs more money.
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.
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 health 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 by the federal government 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, your health insurance company will treat the drug as “covered” under the plan, but will likely also charge a co-pay.
Expanded Drug Coverage
Prior to the ACA, 9 percent of individual market plans did not cover prescription drugs. The ACA expanded drug coverage by requiring marketplace plans to “ cover at least one drug in each drug class” and to count out-of-pocket drug expenses toward a beneficiary’s deductible. By expanding Medicaid eligibility as well as broadening the Medicaid Drug Rebate Program, the ACA gave more low-income Americans access to brand-name and generic drugs and lowered the costs for taxpayers.
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 diagnosed 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.
While that list alone may seem impressive, it’s even more impressive when you look at the long list of preventive healthcare services that are covered FREE under ACA-compliant plans:
- FREE colonoscopies
- FREE route cholesterol and blood pressure checks
- FREE birth control
- FREE routine vaccinations
- FREE breastfeeding supplies
- FREE screening for gestational diabetes
- FREE pap smears and HPV tests
- FREE screenings for HIV, Gonorrhea, and Hepatitis
- FREE tobacco cessation
- FREE Rh incompatibility screening for pregnant women
ACA’s Consumer Protections/ Anti-Discrimination
Obamacare’s Health reform has been lauded for its many provisions designed to expand coverage – and to prohibit discrimination.
Protection from discrimination
Section 1557 prohibits discrimination in health plans – including discrimination based on gender identity or sexual orientation. That has been a boon to the LGBT community.
The Trump administration rolled back those consumer protections with a new rule that was issued in 2020, but the Biden administration announced in May 2021 that Section 1557 requirements would once again include a prohibition on discrimination by health care entities based on sexual orientation or gender identity. And HHS has included clarification of the non-discrimination rules in the proposed Benefit and Payment Parameters for 2023.
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.
Medicare was Improved as Well
Medicare’s eligibility standards did not change under the ACA (although some things were improved, such as additional preventive care and the closing of the Part D donut hole). That means those on social security saw improved health care insurance coverage as well.
Positive Impact on Small Businesses
The ACA can provide an incentive for businesses to keep their employee count artificially low, as only businesses with 50 or more employees are required to provide health insurance for their employees. This can affect how many people are employed full-time by small businesses. However, and though this was a concern to begin with, it has not proven to be the case. Most small businesses have come to appreciate the ease with which the can offer health insurance and thus remain competitive with much larger businesses. Being able to offer affordable medical care to their employees through ACA health insurance plans has actually been shown to be a tremendous employee retention tool.
A Fiorella Insurance agent or broker can help you through the entire process.