Since the opening of the new Health Insurance Marketplace, the Affordable Care Act, more popularly known as the ObamaCare, has been dominating headlines. Amid all the technical glitches, misunderstandings and controversy, the many positive changes that this law is expected to bring seem to have gotten lost in the shuffle. One of these changes is that all health insurance plans that are offered directly to individuals or provided to employers having 50 or fewer employees through the small-group market are required to offer coverage for an EHB (Essential Health Benefits) package. Now, to refresh you on what the ObamaCare covers, read on.
What Benefits the ObamaCare Covers
Under this law, your healthcare expense is covered if the benefits under your plan are applied to the service or item. On the other hand, if the cost is not covered, then the benefits will not be applied, which means that it is your responsibility to pay for the full expense, with nothing going towards meeting your plan’s “out of pocket” limit or deductible. There are also cases where you may still have the responsibility of paying for 100% or just a portion of the cost even if it is covered, but the amount you pay would count towards your co-insurance or deductible. Generally, your insurance policy will cover 100% of the service you have used, as long as your plan benefits apply to such service, as it is considered a covered benefit. To put it simply, the extent of the coverage depends on the item or service, as well as on the type of your health insurance plan, and the terms of covered benefits will change from one health insurance policy to another.
What Are Its Four Tiers of Coverage
Under the ObamaCare, there are 4 tiers of health insurance plan coverage, of which names are taken from various metals, namely platinum, gold, silver and bronze. These 4 levels are separated based upon their actuarial values or the average percentage of healthcare costs to be paid by the insurance plan. The actuarial values of these 4 tiers of coverage are Platinum – 90%; Gold – 80%; Silver – 70%; and Bronze – 60%. Basically, the higher the metallic level is, the more the plan would pay for your health bills (with higher monthly premiums as well). However, regardless of the type of policy you have taken out, your expenses will be covered by a core set of EHB.
What Are the Items and Services Covered by the ObamaCare
The ObamaCare mandates that health plans, which are not existing on March 23, 2010 (the so-called non-grandfathered health plans) and offered outside or inside the new Health Insurance Marketplace by individual and small group markets, should cover a core package of healthcare services, which are pertained to as EHB. Here are the 10 general categories the Affordable Care Act covers:
Emergency Services – These are generally the care that you will receive for conditions that might lead to death or serious disability without immediate attention, such as sudden illness or accident. Usually, this will require a trip to the emergency room on an ambulance. With this, you will not be penalized for not having prior authorization or going out of network.
Ambulatory Patient Services – You will receive these services without being admitted to a hospital, such as an out-patient surgery center, a clinic or a doctor’s office. This category also includes hospice care and home health services.
Laboratory Services – This category covers performed tests that help doctors diagnose a condition, illness or injury and monitor a particular treatment’s effectiveness. Under the ObamaCare, some preventive screenings, such as those for breast and prostate cancer, are offered free of charge.
Hospitalization – You receive this service as a hospital patient, where you get care from physicians, nurses and other staff of the facility, laboratory tests and other examinations, medications, and room. Coverage for hospitalization also includes transplants, surgeries and care you receive in a skilled nursing facility, such as a nursing or elderly home.
Mental Health Services and Addiction Treatment – This category includes outpatient and inpatient care that is provided to diagnose, evaluate and treat a substance abuse disorder and mental health condition.
Maternity and Newborn Care – This is the type of medical service that women will receive during their pregnancy and throughout labor, delivery, post-delivery and care for their newborns.
Pediatric Services – This category covers care that is offered to children and infants, of which services include recommended immunizations and vaccinations, as well as well-child visits. For vision and dental care, it must be offered to children below 19 years of age, covering an eye exam, corrective lenses change every year and 2 routine dental exams.
Rehabilitative Services and Devices – These include habilitation and rehabilitation devices and services to help a patient with recovering or gaining physical and mental skills that were lost to a chronic condition, disability or injury. For the insurance plans, they have to provide 30 visits every year for either occupational or physical therapy, as well as visits to the chiropractor. Also, they must cover the same number of visits per year for speech therapy and cardiac or pulmonary rehabilitation.
Preventive and Wellness Services and Chronic Disease Treatment – This is preventive care, such as immunizations, physical check-ups and cancer screenings that are designed to detect and prevent particular medical conditions. In addition, it includes care for chronic conditions, such as diabetes and asthma.
Prescription Drugs – This category includes prescription medicines that are used to treat a condition or illness, such as prescription antibiotics for treating an infection and medications used for treatment of an ongoing condition, such as high-cholesterol level. Remember that at least one prescription drug should be covered for each classification and category of drugs that are federally approved.
Under the ObamaCare, these 10 EHB and certain preventive health services are the minimum requirements for health insurance policies. Those that already exist on March 23, 2010, such as self-funded plans, fully insured large group plans and grandfathered plans, are not required to include these benefits. The plan you take out might have additional benefits on top of the EHB, so make sure you look at its summary of benefits.