ESSENTIAL HEALTH BENEFITS
Under the law, health insurers must cover 10 essential benefits. This will make health plans more costly, but also more comprehensive. Starting next year, the rules will apply to all plans offered to individuals or through the small-group market to employers with 50 or fewer workers. The essential-benefits requirement does not apply to plans offered by larger employers, which typically offer most of these, already.
The covered benefits are: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative services and devices; laboratory services; management of chronic diseases, and preventive and wellness services; and pediatric services, including dental and vision care.
People will be able to pick from insurance plans with differing levels of coverage and varying costs for co-pays and premiums. But insurers will have to cover a certain percentage of the services’ cost.
“Most of the important services people need are covered, though there may be a slight variation (from state to state),” says Jennifer Tolbert, director of state health reform for the Kaiser Family Foundation.
Need a teeth-cleaning or eye exam? You still could be reaching into your own wallet to cover the cost even after the Affordable Care Act takes full effect next year. Dental and vision care is considered an essential benefit for children aged 18 and younger whose parents or guardians get insurance through the individual or small-group plans. The law does not mandate this coverage for adults, but some states could choose to have them covered.
Still, getting dental coverage for children and teenagers might be a bit complicated depending on where you live. States can choose to offer those items as stand-alone plans, and federal subsidies would not help pay for the costs.
This is a major change under the law. Starting in 2014, most plans — whether obtained through an employer or on the marketplace — cannot deny coverage or charge more money because of a pre-existing health conditions.
However, if you have what is known as a grandfathered individual plan — a plan you buy yourself that was in existence before March 23, 2010, and has remained unchanged — then this rule would not apply. So check the details on your plan and consider shopping around.
OUT-OF-POCKET SPENDING/LIFETIME LIMITS
Under the law, the amount of money people will have to pay out-of-pocket each year for medical and prescription drug costs will be capped at $6,350 for individuals and $12,700 for a family. These limits are separate from the monthly premiums people pay. The limits take effect in 2014 for those buying insurance on the state health insurance exchanges. For those with employer-based coverage, the restrictions will be fully in place in 2015.
In addition, most insurance plans will be prohibited from setting lifetime cost limits on coverage for essential health benefits. This means your insurer cannot deny you coverage because your medical bills have gone over a certain amount.
One popular provision of the health care law already is part of most insurance plans — allowing young people to stay on their parents’ insurance plans until age 26. This also covers dependents, including step-children, adopted children and some foster children. This benefit will be required of all plans that provide dependent care. Starting in 2014, younger people can remain on a parent’s or caregiver’s plan even if they have an employer option of their own.