If you’ve ever had health insurance, you’re probably all too familiar with what your plan won’t cover; the list of expenses denied when you try to file a claim can seem endless. It’s easy to wonder what is covered.
But this week Americans got a lot more clarity about what health insurance plans must cover starting in January 2014, thanks to the Affordable Care Act (ACA). The U.S. Department of Health and Human Services (HHS) just published its list of what it calls “essential health benefits.”
These ten new categories apply to both individual and small employer plans, as well as new plans under Medicaid that will cover, for the first time, low-income adults even if they don’t have kids. And some large employers who provide health insurance may add in some benefits from the new list as well.
The Affordable Care Act Won't End Disparities
It’s a strong list, and includes, importantly, coverage for mental health and substance abuse treatment—not currently part of many health insurance plans. But the specifics of what you get—such as how many days of in-patient treatment for drug abuse—will be left up to each insurance plan. Those specifics will also be determined by how much you pay for coverage.
When signing up this fall for insurance, New York City resident Kim L. is hoping for an affordable insurance plan with outpatient coverage. His bill for a $40,000-plus stay at an inpatient facility for seven weeks over the summer of 2012 to treat alcohol and antidepressant abuse was waived by the facility because he knew one of the doctors. But his business failed while he was away, and he let his health insurance lapse. He’s hoping a new, affordable plan will come with outpatient counseling to help him stay clean.
What Kim, or anyone else, pays depends on the type of plan they choose. The new rules allow insurers to have “metal levels”—platinum, gold, silver, and bronze—that charge different rates for premiums, deductibles, and co-pays. As you might guess, the specific benefits you get for each depend on what level you pay for.
Simply put, the broad categories of treatment and care that each plan must provide–thanks to this week’s rules—include:
• outpatient medical care
• emergency care
• hospitalization
• maternity and newborn care
• mental health and substance use disorder services
• prescription drugs
• rehabilitation services and devices
• lab tests
• preventive and wellness services and chronic disease management
• pediatric services, including dental and vision care
The devil may be in the details, though: Breastfeeding supplies are a good example. Coverage for the supplies actually went into effect last August, but insurance plans have leeway on what they provide. Not all offer lactation consultant services, for example.
In response to the release of the new essential health benefits standards, Robert Zirkelbach, a spokesman for the American Association of Health Insurance Plans, a leading industry lobbying group, said, “The minimum essential health benefits standard will still require many individuals and small businesses to purchase coverage that is more comprehensive and more expensive than they choose to purchase today.”
All the more reason for people planning to buy new insurance under the ACA to be well-informed when the exchanges open on October 1.
The HHS offers a checklist for individuals, families, and small businesses to get ready for enrollment, including a list of questions to ask health insurance plans, a primer on insurance basics, and help budgeting for insurance.
Have you given any thought to your health insurance under the coming changes from the Affordable Care Act? Do you know if you’ll stick with the plan you have or choose something new?
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Fran Kritz is a freelance writer specializing in health and health policy who lives in Silver Spring, Maryland. Takepart.com